Quality street

New conditions added to the national clinical audit programme commissioned by the Healthcare Quality Improvement Partnership (HQIP) include prostate cancer, learning disabilities and COPD. HQIP has also made public (rather ahead of schedule) guidance on what makes a good or effective clinical audit. At the somewhat more theoretical level a paper from the RAND Corporation asks How do quality improvement interventions succeed?

Cancer update

Radiotherapy following breast cancer surgery is beneficial, according to a meta analysis published in the Lancet, with recurrence rates over 10 years halved and death rates over 15 years reduced by about a sixth. Analysis of geographical variations in cancer survival in England from the Cancer Network suggests that although the North-South divide has become less marked over time, geographical inequalities nevertheless persist. the study's authors suggest that the trend in breast cancer survival, where geographical inequalities are lessening, may be followed by other cancers in time. The Whitehall II study continues to offer up opportunities for new analysis: amongst which an assessment of risk factors for colorectal cancer. This 40 year follow up finds smoking to be a significant risk.

You say you want a revolution

The NHS information revolution was the focus of a conference hosted by the King's Fund recently. You can catch up with some of the presentations online, via the King's Fund webpages. Highlights include a paper on meeting the information needs of Clinical Commissioning Groups (CCGs) and another on the relationship between information, patients and choice, as well as a keynote address from Sir Muir Gray on what he is pleased to call the third healthcare revolution of knowledge, information and value. Also at the conference Giles Wilmore, Director of Quality Framework and QUIPP Programmes at DH, announced that publication of DH's new information strategy could not be expected before next spring (a second deferral for the unveiling of these plans). The Health Service Ombudsman's rather critical report on complaints handling in the NHS includes a plea for the information revolution to spread to information about complaints.

False positives

The debate over the value of the UK Breast Cancer Screening programme reached a wider audience today, as the media picked up Mike Richards' announcement in the BMJ of an independent review. A recent Cochrane review has suggested that screening for breast cancer "seems likely to reduce breast cancer mortality" but the level of reduction is small. Moreover the extent of disbenefit from unnecessary treatment for misdiagnosed healthy women, along with psychological distress, means that it is "not clear whether screening does more good than harm."

Nothing about me ...

... was well on the way to becoming reality as Andrew Lansley launched the Right Care shared decision making programme. Under the lovely mantra "Right Care, Right Patient, Right Place, Right Time," the thinking behind this policy is driven by the patient empowerment agenda that has run through the government's health reforms. The NHS Right Care site provides an update on the roll-out of the programme and the publication of Patient Decision Aids (hosted by NHS Direct). A team from Imperial College's School of Public Health asks whether shared decision making involving patients with chronic musculoskeletal pain and various healthcare professionals improve patient care.

Take care

There's a week for everything, and from 14th to 20th November it's National Self Care Week. This year's campaign is being run in partnership with the Self Care Forum.
Meanwhile, here's an update of recently published work on self management:
The crucial role of information in supporting self care is examined in a review of how self management is applied in conditions like heart disease and kidney disease. Another review looks at evidence for patient self-management and access to healthcare services for ethnic minority groups living with diabetes. The British Journal of Cardiac Nursing offers a descriptive study of self management behaviours amongst patients with heart failure in Scotland. A qualititative study of primary care practices in the north of England assesses how self management issues are handled in general practice consultations where computer based disease management templates are also used.

Just checking

The idea of a postcode lottery often claims attention: a recent article in BMC Public Health considers how far this term can be applied to the outworkings of the Health Check as delivered in North West London. The study looked at how NHS Health Checks worked in 8 PCTs in the area, finding considerable variation, with substantial differences in funding levels and in how the programme was interpreted and implemented. Another study, this time from Stoke on Trent, looks at options for cost effective delivery of the Health Checks programme, comparing drop in clinics with booked appointments and considering the merits of targeting particular age groups.

It's going to get personal

The government has announced that it will implement personal health budgets for people receiving continuing care by April 2014. While the small print states that this is subject to evaluations of the current pilot programmes, these are due to report in October 2012, so this announcement looks slightly like jumping the gun. The NHS Confederation, which has been considering the matter for some time, has issued a paper summarising the results of its research.

Primary Colours Issue 45

Primary Colours Bulletin, Issue 45, a round up of all the blogs for the last month is available on the EPHRU website

Not quite the tooth fairy

Much commented on in the press is a systematic review of the benefits of sugar-free products for dental health. The researchers found something of a swings and roundabouts situation: while sugar-free products may help to prevent dental caries, they often also contain acidic flavourings and or preservatives that are damaging to dental enamel. The article goes on to discuss the status of health claims for food: one of the sweeteners singled out for analysis, xylitol, has been approved for marketing as "tooth friendly" and is a common ingredient in chewing gum. The study's authors warn that "the term sugar-free may generate false security because people may automatically believe that sugar-free products are safe on teeth." A recent review of non-fluoride preventive measures for dental caries from the American Dental Association (ADA) considered the evidence for using sugar-free chewing gum preventively was not overly strong. This did not, however, prevent an article in Dentisty.co.uk from suggesting that xylitol had been given the "thumbs up," while the ADA's study merely notes that in high risk patients these treatments may be useful adjuncts to usual care including changes in diet and use of fluoride.

To strategically go

Strategic commissioning is being embraced by local authorities as the way forward for public service delivery, according to a report from local government think tank Localis (in partnership with Essex County Council and Mears). Commission Impossible draws on findings from a survey of council leaders and chief executives which shows that the practice of commissioning services from outside providers is widespread and "set to accelerate significantly." While various healthcare press reports focus on the make-up of newly formed clinical commissioning groups (CCGs), a paper from the NHS Confederation and Royal College of General Practitioners addresses the oft-raised question of conflicts of interest and offers some timely guidance. In an article for Pulse, the chair of the Tower Hamlets CCG summarises this group's approach to integrated commissioning, joining the dots between primary and secondary care and local authority provision. This month's expert on call from the NHS Institute features Mark Jennings, Senior Advisor to the Development for Commissioners Programme, focusing on integration and commissioning.

Experience counts

A useful survey of the state of play on measuring patient experience in primary care is provided by King's College London's Policy+ newsletter. Research published in Quality and Safety in Healthcare looks at the reasons why patients from ethnic minorities and some other patient groups "consistently report lower scores on patient surveys." While a substantial element of the difference for BME patients "reflected concentration of ethnic minority patients in low-performing practices," this was not the case for younger patients and those with poor self-reported health. Telling patients when mistakes have been made is likely to be a contractual obligation, if government proposals are adopted. DH has issued a consultation paper on implementing a duty of candour for NHS providers, as part of its efforts to enhance accountability. Patient safety group Action Against Medical Accidents has expressed concern that this duty should be statutory rather than contractual, according to HSJ.

Risk assessments are the key

Not a popular position to take, but this is exactly what a clinical review in the BMJ proposes, as regards falls prevention. Falls risk screening, as recommended by NICE and the American British Geriatric Society guidelines, really works. The review also includes some video footage of assessments. A study from King's College London's Institute of Gerontology considers the possibility of a community partnership with the fire and rescue services.

Known unknowns

There's no question that good quality evidence is needed for public health policy development and decision making. But some topics are better served than others. A study by a team from McMaster University in Ontario attempts to map usage, quantity and quality of review level evidence coverage in a range of public health topics. The researchers, who examined the contents of the Canadian health-evidence.ca site, found that social determinants of health and healthy communities were amongst those most lacking in review evidence.

Integrate!

A quick summary of what integrated care could mean for the NHS has been published by the King's Fund. It summarises an earlier report by King's Fund Chief Executive Chris Ham. The Royal College of General Practitioners (RCGP) is seeking the collective wisdom of its membership on the matter of integration. In a consultation paper published last month, the College asks about system design, payment systems and effects on GP practice boundaries, amongst other issues. Responses are due in by 31 October 2011. Meanwhile a paper from the Nuffield Trust looks at the contribution commissioners can make in promoting integration.

Counting the cost

Prescribing analogue insulin, rather than human insulin, is an expensive option for the NHS. A recent study suggests that, between 2000 and 2009, this was something like £625 million. NICE guidelines recommend human insulin as the first choice of therapy, however. An interesting study in Social Science and Medicine looks at how NHS managers evaluate exceptional requests for high-cost drugs, based on the work of a Welsh individual patient commissioning panel.

Cheap at half the price?

The lack of rigorous cost effectiveness data for public health interventions has often been noted. This, coupled with the rather colder funding climate has lead NICE (the National Institute of Health and Clinical Excellence) to offer a meta-analysis of cost effectiveness data produced in the development of NICE's own public health guidance. Unsurprisingly, NICE has found that the majority of interventions assessed "are highly cost effective."