Feeling the crunch: NHS finances to 2020

Gainsbury S (2016) Feeling the crunch: NHS finances to 2020. Research summary. Nuffield Trust

As recognised by the NHS’s Five Year Forward View, by 2020 the NHS will need to find savings of around £22 billion in order to balance its books. But there has been no clear articulation of how that gap is expected to be closed. The options for doing so include NHS providers becoming more efficient; NHS commissioners reducing the pace at which NHS activity is increasing each year, either through reducing demand or limiting access to care; more funding for the NHS; or some combination of these. This analysis examines different scenarios to determine exactly what it would take to close the gap.

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How GPs in London are reducing hospital referrals

Thomas, K. The Guardian. Published online: 9 August 2016

New software enables GPs to confer with local hospital consultants to get advice on whether to refer a patient or not

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Charlotte Levitt, a GP based in south London, faced a dilemma. One of her patients was taking a drug that had just come onto the market and his kidney function had started deteriorating. Should she refer the patient to a consultant, or take him off the drug?

Whereas many GPs might automatically make a referral, Levitt, referral management lead at Wandsworth clinical commissioning group (CCG), was able to resolve the question quickly. She logged on to Kinesis, web-based software from Cloud2 that enables GPs to confer with local hospital consultants. In this case, the consultant advised further blood tests: if they were abnormal, the patient should be referred. If not, the drug was likely to be the problem.

Last year, there were 13.6m GP referrals in England, a 5% rise on the previous year, representing an increasing cost burden on CCGs. A 2009 report from the NHS Institute for Innovation and Improvement found that up to 65% of patients referred to outpatient specialty clinics were discharged with “no significant pathology detected”, meaning many were unnecessary.

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Cultural Shift Can Aid Improvement in Department-Specific Hand Hygiene Practices

Infection Control Today. Published online: 7 August 2016

Tolson and Friedewald reviewed a hand hygiene program, inclusive of audit methodology to measure compliance, at a local health district in NSW, Australia. The review resulted in a ‘whole-of-organization’ approach being endorsed which incorporated non-patient areas; these included sterilization services departments.

Sterilization services department managers elected to participate in the revised organizational approach. New signage was posted at identified hand hygiene performance points in the departments, with alcohol-based handrub dispensers mounted below each sign. Consultation occurred with department staff about the proposed hand hygiene audit program and anticipated benefits for all staff to be involved. An audit tool was developed based on the department’s core activities for which hand hygiene performance was considered essential. The tool was trialed and following amendments, implemented for ongoing use. All staff participated as auditors on a rotational basis. Results were shared at staff meetings.

Tolson and Friedewald report that initial compliance rates were lower than expected. The results raised staff awareness that improvement was required. Over an 18-month period, the total compliance rate increased from 43 percent to 88 percent.

The researchers say that development of a tailored audit tool, involvement of all staff members as auditors, and the timely sharing of results, can be effective in developing a cultural shift to aid improvement in department-specific hand hygiene practices.

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Improved Administration of Antibiotics in the Emergency Department: A Practice Improvement Project

McLaughlin, J.M. et al. Journal of Emergency Nursing.July 2016. 42(4). pp. 312–316

hospital-834150_960_720Problem: Although consensus exists among experts that early intravenous antibiotic therapy has an impact on patient mortality, the medical literature includes little information about ensuring that the patient receives the complete dose. At our emergency department, it had become standard clinical practice to administer antibiotics with primary pump tubing and an infusion pump. Clinical pharmacy staff identified this practice as a cause for concern, because at least 20 mL (up to 40%) of the dose volume remains in the tubing. This practice improvement project was aimed at improving the administration of antibiotics by programming a secondary infusion to ensure the complete dose would be administered.

Methods: A multidisciplinary educational intervention was initiated consisting of one-on-one instruction with each emergency nurse (n = 103) at the department’s annual Skills Sessions, distribution of educational tip sheets, and reinforcement of the proper procedure at the patient’s bedside. Emergency nurses were educated via simulation regarding correct secondary pump programming, using smart pump technology.

Results: Surveys indicated that 8% of emergency nurses used secondary tubing along with a smart pump to administer antibiotics before the intervention, compared with 96% after the intervention (P < .0001).

Implications for Practice: This project demonstrates that our educational intervention improved awareness of the need to administer the entire antibiotic dose and adherence to the use of secondary tubing along with smart pump technology to administer antibiotics.

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Usage, adherence and attrition: how new mothers engage with a nurse-moderated web-based intervention to support maternal and infant health. A 9-month observational study

Sawyer, M.G. et al. BMJ Open. 2016. 6:e009967

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Objectives: To identify factors predicting use, adherence and attrition with a nurse-moderated web-based group intervention designed to support mothers of infants aged 0–6 months.

Design:9-Month observational study.

Setting: Community maternal and child health service.

Participants: 240 mothers attending initial postnatal health checks at community clinics who were randomly assigned to the intervention arm of a pragmatic preference randomised trial (total randomised controlled trial, n=819; response rate=45%).

Intervention: In the first week (phase I), mothers were assisted with their first website login by a research assistant. In weeks 2–7 (phase II), mothers participated in the web-based intervention with an expectation of weekly logins. The web-based intervention was comparable to traditional face-to-face new mothers’ groups. During weeks 8–26 (phase III), mothers participated in an extended programme at a frequency of their choosing.

Primary outcome measures: Number of logins and posted messages. Standard self-report measures assessed maternal demographic and psychosocial characteristics.

Results: In phase II, the median number of logins was 9 logins (IQR=1–25), and in phase III, it was 10 logins (IQR=0–39). Incident risk ratios from multivariable analyses indicated that compared to mothers with the lowest third of logins in phase I, those with the highest third had 6.43 times as many logins in phase II and 7.14 times in phase III. Fifty per cent of mothers logged-in at least once every 30 days for 147 days after phase I and 44% logged-in at least once in the last 30 days of the intervention. Frequency of logins during phase I was a stronger predictor of mothers’ level of engagement with the intervention than their demographic and psychosocial characteristics.

Conclusions: Mothers’ early use of web-based interventions could be employed to customise engagement protocols to the circumstances of individual mothers with the aim of improving adherence and reducing attrition with web-based interventions

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