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PubMed1997

Explaining breast cancer mortality in England: the effect of socioeconomic factors and health care services.

England has the worst mortality rate for breast cancer in the developed world. Using area-level data for 145 health districts in England, this study seeks to explain variations in breast cancer mortality among women aged 50-64 years in the period before the National Breast Screening Programme became operational. It is found that socioeconomic and behavioural factors had a larger effect on mortality than did health care inputs. This might be explained both by inadequacies in the data, and by the fact that, in the absence of screening, cancers tend to be detected at a later stage, by which time the chances of a successful outcome are reduced. It is suggested that the impact of health care services in reducing mortality will increase in the future as screening becomes widespread and results in earlier detection and treatment. The prioritization of screening is central to achieving the reductions in mortality from breast cancer specified in the Health of the Nation targets.

Aged↗
PubMed1998

Patients consulting with Crohn's disease in primary care in England and Wales.

OBJECTIVE: To determine annual incidence and prevalence for patients consulting their GP because of Crohn's disease in England and Wales and compare demographic details with matched controls. DESIGN: We used the fourth Morbidity Statistics in General Practice study (MSGP-4) which covered 468 042 person-years during a 12-month period in 1991-92. METHODS: All GPs reporting a patient with Crohn's disease in MSGP-4 were sent a questionnaire to confirm the diagnosis and obtain supportive details (surgical, pathological, radiological and/or endoscopic). Data concerning ethnicity, social class, smoking status, living in an urban or rural environment and employment had been collected previously. Conditional logistic regression models were used to analyse the data for cases and matched controls. RESULTS: Three hundred and fifteen patients were reported to have Crohn's disease. Replies were obtained to 251 (80%) questionnaires. The diagnosis of Crohn's disease was confirmed in 184 cases (89%) and refuted in 23 cases (11%) -- details were unavailable for 44 patients. The mean age of patients was 44 years, the female:male ratio was 1.46:1, and 108 (59%) patients had required surgery. Thirty-three of 178 (18.5%) patients were diagnosed within the study period. Hence, this study detected a prevalence for consulting Crohn's disease of 54.6-59.8/100,000 and an annual incidence of 10.1-11.1/100,000 in 1991-92. No significant differences were found between cases (n = 291) and controls (n = 1682) with regard to ethnicity, social class, smoking or living in an urban/rural environment. Patients with Crohn's disease had similar employment levels as controls, but were significantly more likely to be registered as permanently sick, odds ratio 4.01 (CI 2.21-7.29). CONCLUSIONS: This national survey, including 1% of the population, suggests there are approximately 30,600 patients consulting their GP because of Crohn's disease in England and Wales, with 5700 new cases diagnosed per year.

Adolescent↗
PubMed2005

HIV prevalence among injecting drug users in England and Wales 1990 to 2003: evidence for increased transmission in recent years.

OBJECTIVE: To describe trends in HIV prevalence among injecting drug users in England and Wales between 1990 and 2003. METHODS: Analysis of surveillance data from voluntary unlinked anonymous cross-sectional surveys collecting oral fluid samples and behavioural information from injecting drug users recruited from both drug agency (n = 24,304) and community settings (n = 3628). RESULTS: HIV prevalence in England and Wales declined from 5.9% in 1990 to 0.6% in 1996 and then remained stable until 1999, after which it increased to 1.4% in 2003. Few HIV infections were detected among short-term injectors between 1994 and 1999, but in recent years prevalence among this group has increased. Other factors associated with higher odds of HIV infection were being recruited in London and from community settings, and ever having had a voluntary confidential HIV test. Incidence estimated through a force of infection model was 2.8% per annum among those injecting for less than a year in London between 1998 and 2003. CONCLUSIONS: These data suggest that incidence and prevalence of HIV may have increased, whereas other indicators suggest an increase in risk behaviour. It is critical that harm reduction measures are reinvigorated, and evolve in response to changes in drug use risk behaviours and policy.

Adolescent↗
PubMed2004

Variation in the management of pediatric splenic injuries in New England.

BACKGROUND: Nonoperative management of stable children with splenic injuries is the standard of care but has been variably applied in New England. The influence of surgeon training on this variation was analyzed. METHODS: A region-wide administrative data set was queried for children with a splenic injury from 1990 through 1998. The influence of a range of patient- and hospital-specific variables, including surgeon pediatric training, on the risk of operation was analyzed. RESULTS: The risk of operation increased with age, severity of splenic injury, and the presence of multiple injuries, but also trauma center status and the presence of a surgical training program. After allowance for these variables, the risk of operation was reduced by half when children with splenic injuries were cared for by a surgeon with pediatric specialty training. CONCLUSION: The risk of operation for pediatric splenic injury in New England is dependent on several variables, including the surgeon's training.

Adolescent↗
PubMed2004

Costs and quality in the treatment of acute depression in primary care: a comparison between England, Germany and Switzerland.

No study has yet compared the costs and quality of depression treatment between European countries. The present study aimed to compare the costs and quality of treatment for the first manifestation of an acute major depression in England, Germany and Switzerland. Seventy-four randomly selected physician practices assessed their services for one hypothetical average patient (cost evaluation) and 73 practices reported retrospective data on one real patient (quality evaluation) for the year 2001. Reimbursement fees served as unit costs for Germany and Switzerland. Average reimbursement fees were used to measure resource utilization in all countries. Resource utilization was lowest in Switzerland. The percentage of patients receiving evidence-based treatment for major depression was insignificantly higher in Switzerland and England compared to Germany (56%, 52% and 35%, respectively; P>0.30). Switzerland was both the most effective and the most efficient country (in terms of resource utilization) in providing outpatient treatment for depression.

Acute Disease↗
PubMed2005

A Romani mitochondrial haplotype in England 500 years before their recorded arrival in Britain.

The nomadic Romani (gypsy) people are known for their deep-rooted traditions, but most of their history is recorded from external sources. We find evidence for a Romani genetic lineage in England long before their recorded arrival there. The most likely explanations are that either the historical record is wrong, or that early liaisons between Norse and Romani people during their coincident presence in ninth to tenth century Byzantium led to the spread of the haplotype to England.

DNA, Mitochondrial↗
PubMed1989

Pertussis in England and Wales: an investigation of transmission dynamics and control by mass vaccination.

The epidemiology of pertussis and its prospects for control by mass vaccination in England and Wales are investigated by analyses of longitudinal records on incidence and vaccine uptake, and horizontal data on age-stratified case reports. Mathematical models of the transmission dynamics of the infection that incorporate loss of natural and vaccine-induced immunity plus variable vaccine efficacy are developed, and their predictions compared with observed trends. Analyses of case reports reveal that the individual force of infection is age dependent, with peak transmission in the 5- to 10-year-old age class. A model incorporating this age dependency, along with partial vaccine efficacy and loss of vaccine-induced immunity, generates predicted patterns that best mirror observed trends since mass vaccination was inaugurated in 1957 in England and Wales. Model projections accurately mirror the failure of mass vaccination to increase the inter-epidemic period of the infection (three years) over that pertaining before control. The analysis suggests that this is due to the impact of partial vaccine efficacy. Projected trends do not accurately reflect the low levels of pertussis incidence reported between epidemics in the periods of high vaccine uptake. This is thought to arise from a combination of factors, including loss of natural and vaccine induced immunity, biases in case reporting (where reporting efficiency is positively associated with the incidence of pertussis), and seasonal variations in transmission. Model predictions suggest that the vaccination of 88% of each birth cohort before the age of 1 year will eliminate bacterial transmission, provided the vaccine confers lifelong protection against infection. If vaccine-induced immunity is significantly less than lifelong (or if vaccination fails to protect all its recipients) repeated cohort immunization is predicted to be necessary to eliminate transmission. Future research needs are discussed, and emphasis is placed on the need for more refined data on vaccine efficacy, the duration of natural and vaccine-induced immunity and the incidence of clinical pertussis and subclinical infections (perhaps by the development of reliable serological tests). Future mathematical models will need especially to incorporate seasonality in transmission.

England↗
PubMed2000

Comparing patients' experience of mental health services in England: a five-Trust survey.

The implementation of the Care Programme Approach (CPA) in English mental health services has been slow to proceed despite general support, both in England and in other countries, of its principles of good practice. This study set out to evaluate the implementation of the CPA directly from patients' experience using the "Your Treatment and Care" assessment tool. The results of a survey of 503 patients across five NHS Trusts in England showed that many patients did not have a copy of their care plan and had not been involved in the care planning procedure. Many reported shortcomings in their experience of their key worker and their psychiatrist. However, there was substantial variation in experience across services. "Your Treatment and Care" showed good internal reliability, was acceptable to users, and appeared to be able to access actual experiences better than a traditional "satisfaction" item. It appears to be very useful as a benchmarking tool and is now being used in services across the UK, the USA and Australia.

Adolescent↗
PubMed2003

Achievements of the first wave personal medical services (PMS) pilots in England. A health authority perspective.

Personal medical services pilots were introduced in England in 1998 to provide increased flexibility to general practitioners practising in deprived areas, to improve service provision and reduce inequalities. The aim of this study was to identify health authority perspectives of the achievements of their pilots. Less than half of the health authorities agreed that their pilots' original objectives had been completely achieved. Support, commitment and enthusiasm from within and outside the pilots, and the ability to be flexible, were helpful in promoting change management. Obstacles were financial difficulties and a lack of understanding of personal medical services. The opinion was that personal medical services had made a highly regarded contribution to the local health economy, especially in the provision of new services and the promotion of new staff roles. The results provide lessons for primary care organisations in England and elsewhere in terms of the factors required to successfully implement change.

Catchment Area, Health↗
PubMed2006

Developing cancer services strategy in primary care in England: primary care trust managers' views of the primary care cancer leads initiative.

PURPOSE: Primary care cancer lead clinicians (PCCLs) act strategically in primary care trusts (PCTs) in England to improve communication and understanding of cancer across primary and secondary care and provide a link between Cancer Networks and primary care. The aim is to evaluate the first three years of the initiative. DESIGN/METHODOLOGY/APPROACH: A postal questionnaire was sent to all PCT chief executives in all PCTs in England and some were passed on to other PCT managers for completion. The response rate was 61 per cent. PCT directors of public health were the largest group of respondents (29 per cent). Most (74 per cent) PCCLs were GPs and 22 per cent were nurses. FINDINGS: PCCLs were most likely to focus on palliative care and preventive services. Key achievements were identified as raising awareness of cancer, developing relationships and promoting primary care. The personal skills of the PCCLs were important as was support of colleagues at all levels. Lack of time was a major barrier to achievement, as was a lack of understanding of the role from others. Links with the Cancer Networks were being developed. About 85 per cent of managers wanted the role to continue. ORIGINALITY/VALUE: The paper illustrates that PCCLs are at the forefront of improving cancer services in primary care. They are particularly important in view of the priority of reducing premature deaths and promotion of healthy lifestyles.

Attitude of Health Personnel↗
PubMed1990

National survey of syringe exchange schemes in England.

This report gives information from an England wide survey of syringe exchange carried out in early 1989. A postal questionnaire was sent to 74 agencies, responses received from 65 (88%), of which 55 were agencies operating syringe exchanges. The development of syringe exchanges has been marked by lack of central coordination, supervision and direction, allowing for local autonomy sensitivity to local conditions and a resulting diversity of practices. Four service models were identified: schemes run by drug agencies; pharmacy-based schemes; specialist stand-alone schemes; and schemes based in non-drug agencies. The average number of different clients per week was 21 and it is estimated that they distributed about one million syringes in the year 1988/89. Pharmacy based schemes presented fewer barriers in terms of access but offered limited services on site, while drug agency schemes presented more barriers in terms of access, but offered more services. The significance of these differences is related to the aims of syringe exchange. In a public health orientation, ease of access to sterile injecting equipment would be the priority and the question of individual help in other areas less important. From a drug problems orientation, the ability to offer clients more services to respond to their wider needs would be a priority. It is estimated that by the end of 1989 there were approximately 120 syringe exchange schemes in England.

England↗
PubMed2006

Pancreatic cancer in England and Wales 1975-2000: patterns and trends in incidence, survival and mortality.

BACKGROUND: Rates and time trends in mortality from pancreatic cancer vary considerably between countries. AIM: To examine trends and patterns in the incidence of, and the survival and mortality from, pancreatic cancer in England and Wales from 1975 to 2000; in particular, whether incidence and survival rates are related to socio-economic deprivation. METHODS: We calculated annual age-specific and overall age-standardized incidence and mortality rates by sex for pancreatic cancer in total, and by subsite. We also estimated survival by sex and age group and by subsite. RESULTS: In males, the age-standardized rate fluctuated in the late 1970s, to peak at 13.0 per 100,000 in 1979, declined steadily by an average of 1.3% per year to around 10.3 per 100,000 in the mid-1990s and then levelled off. For females, the rate peaked at 8.4 per 100,000 in the late 1980s before declining and fluctuating around 7.7 per 100,000 in the late 1990s. Patterns and trends in mortality rates were closely similar to those in incidence, due to the very low survival rates: only 2-3% at 5 years from diagnosis. Survival rates improved only minimally over the period 1971-99. Incidence and mortality rates were slightly higher in both males and females living in the most deprived areas, but survival was not consistently related to socio-economic deprivation. CONCLUSIONS: The incidence of, and mortality from, pancreatic cancer in England and Wales have fallen from peak levels observed in the 1970s and 1980s, and levelled off in the 1990s for both sexes; survival rates remain very low.

Adolescent↗
PubMed2005

Modelling the impact of an influenza pandemic on critical care services in England.

The UK Influenza Pandemic Contingency Plan does not consider the impact of a pandemic on critical care services. We modelled the demand for critical care beds in England with software developed by the Centers for Disease Control (Flusurge 1.0), using a range of attack rates and pandemic durations. Using inputs that have been employed in UK Department of Health scenarios (25% attack rate and 8-week pandemic duration) resulted in a demand for ventilatory support that exceeded 200% of present capacity. Demand remained unsustainably high even when more favourable scenarios were considered. Current critical care bed capacity in England would be unable to cope with the increased demand provided by an influenza pandemic. Appropriate contingency planning is essential.

Bed Occupancy↗
PubMed2005

Hospital admissions for 'drug-induced' disorders in England: a study using the Hospital Episodes Statistics (HES) database.

AIMS: To review Hospital Episode Statistics (HES) data for England coded as being 'drug induced' during 1996-2000 and to consider their potential utility for assessing the public health burden of adverse drug reactions (ADRs) and studying drug safety. METHODS: ICD-10 codes including the words 'drug-induced' or 'due to' a medicine or which are recognized to be invariably caused by a drug were extracted along with external cause codes indicating that a drug was implicated (i.e. Y40-59 in ICD-10). We also calculated the proportions of patients with each 'drug-induced' code for whom an external cause code had been applied. RESULTS: During the 5-year study period there were almost 53.8 million hospital admissions in England, of which 44 411 (0.083%) were coded as 'drug-induced' and 168 958 (0.314%) were associated with a relevant external cause code. The numbers of patients with 'drug-induced' codes used were generally stable during the study period (range 7454-8860 per year) but the application of external cause codes increased in each year and by 40% overall (from 24 786 in 1996 to 34 843 in 2000). The overall proportion of 'drug-induced' codes associated with a relevant external cause code was quite low (12-15%) but there was considerable variation between codes. CONCLUSIONS: Comparisons with published studies indicate that HES data grossly underestimate the burden of drug-induced disorders as a cause of hospital admission. There are likely to be multiple underlying reasons including under-recognition, under-recording and limitations of the coding system. The potential of these data for identifying previously unrecognized serious ADRs is limited by constraints on the availability of detailed data regarding individual cases.

Drug-Related Side Effects and Adverse Reactions↗
PubMed2005

Sea change or quick fix? Policy on long-term conditions in England.

Long-term conditions is a policy area that has risen rapidly up the political agenda in England, culminating in the development of the National Health Service and Social Care Model in 2005, which is to be implemented over the following 2 years. The Model draws heavily upon US ideas of case management and proposes the creation of 3000 community matrons to undertake this role with the most vulnerable patients. Although welcomed in principle, the specific proposals in the Model have been subject to some criticism, and these issues are explored in the present paper. The problematic areas include patient identification, the transplanting of US models to England, the role of case management, workforce and funding issues, and the mix of medical and social models. The author concludes that there is a danger of long-term care policy developing an unduly health-focused approach at a time when the thrust of partnership working is towards an inclusive, whole-system model.

Case Management↗
PubMed1992

The emerging role of the nurse teacher in Project 2000 programmes in England: a literature review.

This paper explores the literature on the role of the nurse teacher in the United Kingdom, in order to support a research study on the role of the nurse teacher as it emerges in Project 2000 programmes in England. Explicit within the reform of nurse education is a change in the role of the teacher. It is being influenced, first, by the creation of colleges of nursing and midwifery and their links to higher education, secondly, by the content and academic level of the course and, thirdly, by the supernumerary status of the student. Studies carried out on the activities nurse teachers undertake highlight the complex and multifaceted nature of the role. Excessive paper work, meetings and lack of autonomy are given as dissatisfying aspects of their work leaving only a small proportion of their time for classroom and clinical teaching. The literature suggests that the nurse teacher is required in Project 2000 to be a nurse, a teacher, a graduate in a specialist subject and clinically and academically credible. The study, which is mentioned briefly in this paper, will critically analyse the key components of the role of the nurse teacher as it emerges in the Project 2000 courses in England. The methodology and findings will be discussed in a later paper.

Counseling↗
PubMed1995

A postal survey of continence advisers in England and Wales.

Improved continence services have been identified as a purchasing priority for 1994-1995. A key figure in the continence team is the nurse continence adviser. However, although the Association for Continence Advice in the United Kingdom offers a set of guidelines for the role of continence adviser, the extent to which these were implemented across the country was unknown. In 1991, the Department of Health commissioned the Social Policy Research Unit of the University of York, England, to carry out a postal survey of all known continence advisers in England and Wales in order to provide basic quantitative information about the number of advisers in post, their professional qualifications, the structures in which they worked, and the nature of current practice. In this paper a brief resumé of some of the main findings from the survey, which included both quantitative and qualitative data, is presented. The role of the continence adviser as a clinical nurse specialist and some of the implications for current practice are also discussed.

Adult↗
PubMed2005

Underweight, obesity and exercise among adults with intellectual disabilities in supported accommodation in Northern England.

BACKGROUND: Significant deviation from normal weight (obesity and underweight) and lack of physical exercise have been identified as three of the most significant global behavioural risks to health. METHODS: Body mass index (BMI) and levels of physical activity were measured in a sample of 1542 adults with intellectual disabilities (ID) receiving supported accommodation in nine geographical localities in Northern England. Comparative population data were extracted from the Health Survey for England 1998 and 2001. RESULTS: Men and women with ID living in supported accommodation are at increased risk of being significantly underweight and physically inactive. Women with ID living in supported accommodation are at increased risk of obesity. Within the population of people with ID living in supported accommodation increased behavioural health risks are associated with gender, severity of ID, age and location. CONCLUSION: Significant deviation from normal weight and lack of physical exercise are significant behavioural risks to health among people with ID.

Adolescent↗