Not recommended reading

It is touching that in finally bowing to pressure to release its review of safe staffing of hospital wards, NICE is sticking to the fictitious line provided by the Department of Health.
This is that NICE did not want to queer NHS Improvement’s pitch, just in case the newly formed regulator had a better (and cheaper) set of recommendations up its sleeve.
We can mock, but the same department that commissioned the review decided to bury it. NICE was merely a victim of government safe-stifling guidelines.
Thanks to the persistence of the HSJ’s Shaun Lintern, NICE has now published the recommendations, but they are both too expensive and too risky to be widely adopted – risky in the sense of career-limiting.
The minister for transparency Jeremy Hunt has just issued a warning that he will suspend the board of any trust that fails to achieve financial balance and keep patients safe.
As he continues to insist that “quality” is both a cause and effect of well-run organisations, Mr Hunt is busy peddling two different and rarely compatible ideas of safety – the financial kind and the real kind.
Any trust that spends more money on quality – by employing more nurses, for example – is highly unlikely to see a sudden and dramatic improvement in its financial position. Mr Hunt knows this, but is compelled to push his logic to breaking point. He is no longer saying that more money won’t necessarily make things better but that less may have an invigorating effect, like a cold shower in the morning.
The formula for success is based not only on a healthy level of self-denial, but on a quasi-religious notion of virtue in which quality and efficiency are indivisible and complementary forces, the sort of thing you might learn if you went to a Jesuit-run business school.
Where a business might invest in quality, public sector finances allow no room for manoeuvre, which leaves us with magic or prayer to fall back on. There is no funny money here. We get what we’re given and when it runs out it’s gone. There are no hedge funds short-selling hospital stocks to offset any losses caused by a rapidly growing population, no rights issues to raise extra cash for social care and no investors queuing for a stake in dementia care, diabetes or emergency departments.
Even so, the minister still appears confused about the difference between funding the NHS and dabbling on the stock markets. “Patients and taxpayers rightly expect a return on this investment,” he says.
Do they? The only potential returns are more life-saving, life-extending and life-enhancing care for every pound spent. In all other senses, the notion of a return is nonsense, as is the idea that financial balance is always possible if we work a bit harder or smarter. The NHS is a money pit.
(Having said that, if any readers are considering investing in the NHS, we have a sub-prime mortgage deal on PFI hospitals you may be interested in.)
Mr Hunt is too clever to believe that berating trusts can possibly achieve the miraculous effect on their finances he demands, but not clever enough to stop.
So while trusts know it would be mad not to follow the newly liberated NICE guidance, they have had a clear signal that it would be madder to follow it.


Religious affairs editor: Julian Patterson


NICE releases safe staffing evidence reviews

Four evidence reviews written to support work NICE carried out on staffing levels in the NHS have been released.

Image source: NICE

Four evidence reviews written to support work NICE carried out on staffing levels in the NHS have been released. Under the Freedom of Information (FOI) Act, the documents had been withheld to give NHS Improvement time to study them in their new remit to consider service improvement. The release of the documents follows an internal review of the FOI decision.

In 2013 the Francis and Berwick reports, published in the wake of care failings at the Mid Staffordshire NHS Trust, identified NICE as a key player to help advise the NHS on staffing levels. The Department of Health and NHS England asked NICE to begin work developing evidence based guidelines focusing on nursing care, one of the main drivers of patient safety.

In July 2014, NICE published the first guideline on safe staffing for nursing in adult inpatient wards in acute hospitals; a second guideline on safe midwifery staffing for maternity settings followed in February 2015. Both were designed to help organisations make decisions about safe and efficient nurse or midwife staffing levels, setting out organisational responsibilities as well as day-to-day actions to be taken on each ward or setting.

In June 2015, NICE was asked to suspend further work on the safe staffing programme as the work would be taken forward by the newly formed NHS Improvement, in conjunction with NHS England. It would become part of a wider programme of service improvement looking at alternative approaches to helping NHS providers achieve the right levels and mix of all healthcare staff.

At the time, work was already underway to produce four evidence reviews in four areas: inpatient mental health settings, adult nursing care in community settings, accident & emergency and management & organisational approaches which support safe staffing in nursing & midwifery.

Image source: NICE

Although all the evidence reviews had not been through the full development process, NICE planned to publish the completed work to date in July 2015. However the Department of Health confirmed to NICE that the information would be published by NHS Improvement as part of its own safe staffing guideline series.

Read the full news release via NICE

How does NHS spending compare with health spending internationally?

John Appleby. King’s Fund Blog: 20 January 2016

The growing gap between us and our European neighbours should give pause for thought.

Comparing spending on health care between countries is not straightforward. We have to consider how to deal with differences in the source of funding: public or private (which will include out-of-pocket spending as well as insurance payments, often compulsory in countries with social insurance systems). Given differences in the way countries fund their health care it is usual to compare total spending (public plus private) expressed as a proportion of countries’ GDP.

On this basis, data from the OECD shows that in 2013 the UK spent 8.5 per cent of its GDP on public and private health care. This placed the UK 13th out of the original 15 countries of the EU:

Image Source: King’s Fund

If we were to close this gap solely by increasing NHS spending (and assuming that health spending in other UK countries was in line with the 2015 Spending Review plans for England), by 2020/21 it would take an increase of 30 per cent – £43 billion – in real terms to match the EU-15 weighted average spend in 2013, taking total NHS spending to £185 billion (see Figure 2).

And of course we may find that by 2020/21 the EU average has moved on, leaving the UK lagging behind its neighbours once more:

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Image source: King’s Fund


Read the full blog via the King’s Fund

Children and young people’s continuing care national framework

framework children
Image source: gov.uk

This guidance is for clinical commissioning groups when assessing the needs of children and young people (0 to 17 years) whose complex needs cannot be met by universal or specialist health services.

The ‘Decision support tool’, which should be used with the framework, provides a structure to help in reaching a decision.

The guide for young people and parents is for use by local health organisations who can add their own contact details.

A network has also been established on NHS Networks for anyone working in this field, to share information, good practice, or seek advice on difficult issues from colleagues. Once you have registered, request to join on the children and young people’s continuing care network page (click on ‘join this network’ when on the page).

The updated framework follows a public consultation. Comments and suggestions received in the consultation are reflected in the new framework.

Read the full guidance via Department of Health

Which painkillers are best for acute pain after surgery?

By Sarah Chapman for Evidently Cochrane // January 22, 2016 

Image source: frankieleon

After any sort of operation, most people are going to have some pain, right? No problem, you say, that’s what painkillers are for. But which? There’s an array of painkillers available but it’s important to know which are most likely to work and least likely to harm us.

The Cochrane Pain, Palliative and Supportive Care Group (PaPaS) has brought together evidence from all the relevant Cochrane reviews in two overviews, one on how effective single dose oral painkillers are for adults in acute pain after surgery and another on how safe.

Investigating which painkillers give the best pain relief

From the 39 Cochrane reviews of oral painkillers, which involved around 50,000 people in 450 studies, the team found reliable evidence on the effectiveness of 53 pairs of drug and dose in all types of surgery. They also found that for some medicines the evidence is unreliable or lacking, which is also important to know.

The effectiveness of the drugs was assessed by the number of people who had at least half the maximum possible pain relief, compared with placebo (dummy pill), expressed as the ‘number needed to treat’ (NNT). The NNT is an estimate of how many people need to have the treatment for one person to have a good outcome. The lower the NNT, the more effective the painkiller is considered to be. This can be helpful when considering treatment options. How long pain relief lasted was also reported.

For the detail of all the drugs investigated you’ll need to go to the full overview, but here are some key points:

  • Fixed dose combination painkillers and fast acting formulations were among the more effective drugs e.g. ibuprofen 200 mg plus paracetamol 500 mg had an NNT of 1.5. Ibuprofen 200 mg plus caffeine 100 mg, ibuprofen 200 mg in a fast acting formulation and diclofenac potassium 50 mg (also fast acting) all had an NNT of 2.1
  • Even the most effective drugs fail to give good pain relief to a proportion of people, more than half the people treated in many instances
  • Longer-acting drugs had lower (better) NNTs and are likely to be more useful and effective
  • For 17 drugs, the evidence is absent or unreliable; none of these are in common use to treat acute pain
  • Useful head-to-head comparisons between drugs were not available

Read the full blog post via Evidently Cochrane


Postmenopausal Osteoporosis

Now@NEJM Blog: Posted by Carla Rothaus • January 22nd, 2016

Management of postmenopausal osteoporosis includes nonpharmacologic treatment (e.g., weightbearing exercise and fall-prevention strategies) and pharmacologic treatment. Bisphosphonates are considered first-line treatment in most women. In a new Clinical Practice article, benefits and rare potential risks are discussed.

Image source: Gtirouflet

Clinical Pearl

• What is the Fracture Risk Assessment Tool (FRAX)?

The overriding goal in managing postmenopausal osteoporosis is the prevention of future fractures. Therefore, identifying women at the highest risk is a clinical priority. Low bone mineral density (BMD), particularly at the hip, is a strong risk factor for fracture: for each 1-SD decrement in BMD, the risk of fracture increases by a factor of 2 or 3. However, a more comprehensive assessment of clinical risk factors is helpful to define absolute risk for an individual and to select patients for treatment. The Fracture Risk Assessment Tool (FRAX), which was developed by the World Health Organization on the basis of data from several international cohorts, incorporates established risk factors and BMD at the femoral neck to predict individual 10-year risk of hip or major osteoporotic fracture; its use is endorsed by several professional organizations.

Clinical Pearl

• What are some of the nonpharmacologic therapies for patients with postmenopausal osteoporosis?

Resistance and weight-bearing exercise can increase muscle mass and can transiently increase BMD. Exercise and balance programs (e.g., yoga and tai chi) may result in improved balance and an increase in muscle tone and may secondarily reduce the risk of falls among some elderly persons. Besides exercise, assessment of the home for hazards, withdrawal of psychotropic medications (when possible), and the use of a multidisciplinary program to assess risk factors are prudent strategies for potentially reducing the risk of falls. Other measures should include counseling about cigarette smoking (which is linked to reduced BMD) and about excess alcohol intake (which can increase the risk of falls).

View the full blog post via now@NEJM

Changes to midwife supervision in the UK

Outlines the changes to the statutory supervision of midwives, which will be introduced in 2017. – DoH

midwifery proposal

These proposals have been developed by the UK Chief Nursing Officers, their midwifery advisors, the Nursing and Midwifery Council, the Royal College of Midwives and a representative of the Local Supervising Authority Midwifery Officers.

The new non-statutory supervision will separate midwifery supervision and regulation. The regulation will be controlled by the Nursing and Midwifery Council. Employers and providers of midwifery services will be responsible for improving the quality of services and support for women through pregnancy, birth and the postnatal period.

Related reports:

Midwifery supervision and regulation: recommendations for change

midwifery proposal2
Image source: ombudsman.org.uk



Harmful drinking and alcohol dependence

Public Health England has published Health matters: harmful drinking and alcohol dependence. This resource provides information on the harmful impact of alcohol dependency. It supports the commissioning and delivery of evidence based treatment interventions to address harmful drinking and alcohol dependence in adults.

image source: http://www.gov.uk

The resource pays particular attention to:

  • The scale of the problem
  • Health inequalities and alcohol dependence
  • Responding to the needs of harmful and alcohol dependent drinkers
image source: http://www.gov.uk

FREE ONLINE COURSE: Dementia – Understanding and Managing Challenging Behaviour

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Image source: FutureLearn


If you are a carer looking after a family member with dementia in your own home or a professional working with people with dementia, this free online course will help you better understand the person and develop the skills needed to manage their challenging behaviour.Understand and manage challenging behaviour

The symptoms of dementia vary (depending on the cause and the individual), but often include memory loss, mood changes, communication and motivation problems, a reduced ability to plan and problems with controlling their own behaviour.

Some symptoms, such as restlessness, agitation and communication difficulties, can be challenging for you as a carer, and this can cause you high levels of stress and burden.

Learn from other dementia carers and academic experts

Dr Alison Coates is a dual-trained adult and mental health nurse and has experience of working in a range of different clinical environments. She is the author of the textbook ‘Nursing Older People’ and currently works at the University of Birmingham teaching mental health nursing with a focus on older adults. Dr Chris Wagstaff has experience of working in a variety of different clinical environments over the past 25 years and has taught widely about a number of different mental health issues. Nutmeg Hallett has a background in forensic nursing, is currently undertaking PhD research investigating violence prevention in clinical settings and is a lecturer in mental health nursing.

In this course, we will use case studies to explore these challenging behaviours and find out how other carers manage them both at home and in a residential care setting. You will explore how using a person-centred approach can reduce challenging behaviours. We will cover specific interventions that can help you, particularly focusing on de-escalation skills.


View the full detail via FutureLearn

If it’s about NHS culture, it’s about leadership

King’s Fund Blog // Michael West: Head of Thought Leadership

Image source: NY

There are plenty of issues to keep NHS leaders awake at night: financial concerns, the winter crisis, the junior doctors’ strikes and experiences of poor-quality care are all in the news. But what about some of the underlying issues behind the headlines?

NHS leaders are concerned about staff reporting high levels of bullying and harassment and are considering strategies to deal with this. They are also concerned with high levels of discrimination reported by some groups of staff and are considering strategies to deal with this.

And there need to be strategies to deal with high levels of staff stress and absenteeism. And then the ambition for the NHS to be the largest learning organisation in the world requires a strategy for ensuring continuous improvement. And there is a need to develop system leadership, which will require yet more strategies. Plus the need to address the shortage of leaders throughout the NHS, which requires a further strategy. So what we end up with is a patchwork of strategies, sewn more or less together in a diffuse set of responses to these important concerns.

Read the full blog via the King’s Fund