Reduction of stillbirths in England from 2008 to 2017 according to uptake of the Growth Assessment Protocol: 10-year population-based cohort study.

OBJECTIVE: Antenatal detection of small-for-gestational age (SGA) can reduce significantly the risk of stillbirth. The Growth Assessment Protocol (GAP) was developed to address the problem that most SGA fetuses are missed antenatally. We set out to analyze the effect that the GAP program has had on stillbirth rates in England. METHODS: We analyzed data from 2008 (the year before roll-out of the GAP program) to 2017 (latest available Office for National Statistics (ONS) unit-based data). The program consists of five elements: training, evidence-based guidelines for risk assessment and surveillance of fetal growth, customized charts, recording of process and outcome indicators, and audit of missed SGA cases. All maternity units in England were categorized into one of three groups according to their GAP status in 2017: (1) not in the GAP program; (2) GAP implemented partially (incomplete adoption of protocol, no monitoring and audit); and (3) GAP implemented completely. A subset of the complete-implementation group comprised the 20 units with the highest SGA detection rates. Unit-level live-birth and stillbirth data were obtained from the ONS for each of these groups. RESULTS: Stillbirth rates declined across all groups from 2008 to 2017, and significantly more in units in which GAP was implemented completely than in the non-GAP units (P < 0.05). The steepest decline in stillbirth rate was observed in the 20 units with the highest SGA detection rates, which had a 24% lower stillbirth rate compared with the units not using GAP (P < 0.01) in 2017. This difference remained significant after mixed-effects logistic regression analysis of potential confounding, including social deprivation (odds ratio, 0.76 (95% CI, 0.64-0.90)). Assessment of the nine Bradford Hill causality criteria and associated characteristics suggested that the association between implementation of the GAP program and reduction in stillbirth rate was causal. CONCLUSIONS: There has been an overall reduction in stillbirth rates in England that is likely to be a result of increased awareness of the importance of antenatal detection of SGA as a key risk factor for stillbirth. The decline in stillbirth rates was significantly greater in maternity units that had fully implemented the GAP program, and was most pronounced in the units with the highest antenatal SGA detection rates. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Reducing Asthma Attacks in Children using Exhaled Nitric Oxide as a biomarker to inform treatment strategy: a randomised trial (RAACENO).

BACKGROUND: Childhood asthma is a common condition. Currently there is no validated objective test which can be used to guide asthma treatment in children. This study tests the hypothesis that the addition of fractional exhaled nitric oxide (FENO) monitoring in addition to standard care reduces the number of exacerbations (or attacks) in children with asthma. METHODS: This is a multi-centre, randomised controlled study. Children will be included of age 6-16 years who have a diagnosis of asthma, currently use inhaled corticosteroids (ICSs) and have had an exacerbation in the previous 12 months. Exclusion criteria include being unable to provide FENO measurement at baseline assessment, having another chronic respiratory condition and being currently treated with maintenance oral steroids. Participants will be recruited in both primary and secondary care settings and will be randomised to either receive asthma treatment guided by FENO plus symptoms (FENO group) or asthma treatment guided by symptoms only (standard care group). Within the FENO group, different treatment decisions will be made dependent on changes in FENO. Participants will attend assessments 3, 6, 9 and 12 months post randomisation. The primary outcome is asthma exacerbation requiring prescription and/or use of an oral corticosteroid over 12 months as recorded by the participant/parent or in general practitioner records. Secondary outcomes include time to first attack, number of attacks, asthma control score and quality of life. Adherence to ICS treatment is objectively measured by an electronic logging device. Participants are invited to participate in a "phenotyping" assessment where skin prick reactivity and bronchodilator response are determined and a saliva sample is collected for DNA extraction. Qualitative interviews will be held with participants and research nurses. A health economic evaluation will take place. DISCUSSION: This study will evaluate whether FENO can provide an objective index to guide and stratify asthma treatment in children. TRIAL REGISTRATION: ISRCTN, ISRCTN67875351. Registered on 12 April 2017. Prospectively registered.

Pharmacoeconomic evaluation of micafungin versus caspofungin as definitive therapy for candidaemia and invasive candidiasis (IC) in Turkey.

Micafungin was shown to be as efficacious as caspofungin in treating patients with candidaemia and invasive candidiasis (IC). However, it remains unknown if micafungin or caspofungin is a cost-effective definitive therapy for candidaemia and IC in Turkey. The present study aimed to determine the economic impact of using micafungin versus caspofungin for treatment of candidaemia and IC in the Turkish setting. A decision analytic model was constructed and was populated with data (i.e. transition probabilities, duration of initial antifungal treatment, reasons for treatment failure, percentage of patients who stepped down to oral fluconazole, and duration on oral fluconazole) obtained from a published randomised clinical trial. Cost inputs were derived from the latest Turkish resources while data that were not readily available in the literature were estimated by expert panels. One-way sensitivity analyses, threshold analyses, scenario analyses and probabilistic sensitivity analyses were conducted. Caspofungin (€2693) incurred a lower total cost than micafungin (€4422), with a net cost saving of €1729 per treated patient. Drug acquisition cost was the main cost driver for both study arms. The model outcome was robust over wide variations (of ±100.0% from the base case value) for all input parameters except for micafungin drug cost and the duration of initial treatment with micafungin. Caspofungin appears to be a cost-saving option in treating candidaemia and IC from the Turkish hospital perspective.

Identifying research priorities for public health research to address health inequalities: use of Delphi-like survey methods.

BACKGROUND: In the funding of health research and public health research it is vital that research questions posed are important and that funded research meets a research need or a gap in evidence. Many methods are used in the identification of research priorities, however, these can be resource intensive, costly and logistically challenging. Identifying such research priorities can be particularly challenging for complex public health problems as there is a need to consult a number of experts across disciplines and with a range of expertise. This study investigated the use of Delphi-like survey methods in identifying important research priorities relating to health inequalities and framing tractable research questions for topic areas identified. METHODS: The study was conducted in two phases, both using Delphi-like survey methods. Firstly, public health professionals with an interest in health inequalities were asked to identify research priorities. Secondly academic researchers were asked to frame tractable research questions relating to the priorities identified. These research priorities identified using Delphi-like survey methods were subsequently compared to those identified using different methods. RESULTS: A total of 52 public health professionals and 21 academics across the United Kingdom agreed to take part. The response rates were high, from public health professionals across three survey rounds (69%, 50% and 40%) and from academics across one round (52%), indicating that participants were receptive to the method and motivated to respond. The themes identified as encompassing the most important research priorities were mental health, healthy environment and health behaviours. Within these themes, the topic areas that emerged most strongly included community interventions for prevention of mental health problems and the food and alcohol environment. Some responses received from academic researchers were (as requested) in the form of tractable research questions, whereas others contributed further potential topic areas instead. CONCLUSIONS: Delphi-like survey methods are practical and productive as a means of obtaining opinions from a wide number of relevant experts identifying potential priority topic areas for research; however, this method is less appropriate for framing tractable research questions.

Using public participation to sample trace metals in lake surface sediments: the OPAL Metals Survey.

Members of the public in England were invited in 2010 to take part in a national metals survey, by collecting samples of littoral sediment from a standing water body for geochemical analysis. To our knowledge, this is the first national sediment metals survey using public participation and reveals a snapshot of the extent of metals contamination in ponds and lakes across England. Hg, Ni, Cu, Zn and Pb concentrations exceeding sediment quality guidelines for the health of aquatic biota are ubiquitous in ponds and lakes, not just in areas with a legacy of industrial activity. To validate the public sampling approach, a calibration exercise was conducted at ten water bodies selected to represent a range of lakes found across England. Sediment concentrations of Hg, Ni, Cu, Zn and Pb were measured in samples of soil, stream and littoral and deep water sediment to assess inputs. Significant differences between littoral sediment metal concentrations occur due to local variability, but also organic content, especially in upland, peat soil catchments. Variability of metal concentrations between littoral samples is shown to be low in small (<20 ha) lowland lakes. Larger and upland lakes with more complex inputs and variation in organic content of littoral samples have a greater variability. Collection of littoral sediments in small lakes and ponds, with or without voluntary participation, can provide a reliable sampling technique for the preliminary assessment of metal contamination in standing waters. However, the heterogeneity of geology, soils and history/extent of metal contamination in the English landscape, combined with the random nature of sample collection, shows that systematic sampling for evaluating the full extent of metal contamination in lakes is still required.

Transcriptome assessment of the Pompe (Gaa-/-) mouse spinal cord indicates widespread neuropathology.

Pompe disease, caused by deficiency of acid alpha-glucosidase (GAA), leads to widespread glycogen accumulation and profound neuromuscular impairments. There has been controversy, however, regarding the role of central nervous system pathology in Pompe motor dysfunction. We hypothesized that absence of GAA protein causes progressive activation of neuropathological signaling, including pathways associated with cell death. To test this hypothesis, genomic data (Affymetrix Mouse Gene Array 2.0ST) from the midcervical spinal cord in 6 and 16 mo old Pompe (Gaa-/-) mice were evaluated (Broad Institute Molecular Signature Database), along with spinal cord histology. The midcervical cord was selected because it contains phrenic motoneurons, and phrenic-diaphragm dysfunction is prominent in Pompe disease. Several clinically important themes for the neurologic etiology of Pompe disease emerged from this unbiased genomic assessment. First, pathways associated with cell death were strongly upregulated as Gaa-/- mice aged, and motoneuron apoptosis was histologically verified. Second, proinflammatory signaling was dramatically upregulated in the Gaa-/- spinal cord. Third, many signal transduction pathways in the Gaa-/- cervical cord were altered in a manner suggestive of impaired synaptic function. Notably, glutamatergic signaling pathways were downregulated, as were "synaptic plasticity pathways" including genes related to neuroplasticity. Fourth, many genes and pathways related to cellular metabolism are dysregulated. Collectively, the data unequivocally confirm that systemic absence of GAA induces a complex neuropathological cascade in the spinal cord. Most importantly, the results indicate that Pompe is a neurodegenerative condition, and this underscores the need for early therapeutic intervention capable of targeting the central nervous system.

Why are most EU pigs tail docked? Economic and ethical analysis of four pig housing and management scenarios in the light of EU legislation and animal welfare outcomes.

To limit tail biting incidence, most pig producers in Europe tail dock their piglets. This is despite EU Council Directive 2008/120/EC banning routine tail docking and allowing it only as a last resort. The paper aims to understand what it takes to fulfil the intentions of the Directive by examining economic results of four management and housing scenarios, and by discussing their consequences for animal welfare in the light of legal and ethical considerations. The four scenarios compared are: 'Standard Docked', a conventional housing scenario with tail docking meeting the recommendations for Danish production (0.7 m2/pig); 'Standard Undocked', which is the same as 'Standard Docked' but with no tail docking, 'Efficient Undocked' and 'Enhanced Undocked', which have increased solid floor area (0.9 and 1.0 m2/pig, respectively) provision of loose manipulable materials (100 and 200 g/straw per pig per day) and no tail docking. A decision tree model based on data from Danish and Finnish pig production suggests that Standard Docked provides the highest economic gross margin with the least tail biting. Given our assumptions, Enhanced Undocked is the least economic, although Efficient Undocked is better economically and both result in a lower incidence of tail biting than Standard Undocked but higher than Standard Docked. For a pig, being bitten is worse for welfare (repeated pain, risk of infections) than being docked, but to compare welfare consequences at a farm level means considering the number of affected pigs. Because of the high levels of biting in Standard Undocked, it has on average inferior welfare to Standard Docked, whereas the comparison of Standard Docked and Enhanced (or Efficient) Undocked is more difficult. In Enhanced (or Efficient) Undocked, more pigs than in Standard Docked suffer from being tail bitten, whereas all the pigs avoid the acute pain of docking endured by the pigs in Standard Docked. We illustrate and discuss this ethical balance using numbers derived from the above-mentioned data. We discuss our results in the light of the EU Directive and its adoption and enforcement by Member States. Widespread use of tail docking seems to be accepted, mainly because the alternative steps that producers are required to take before resorting to it are not specified in detail. By tail docking, producers are acting in their own best interests. We suggest that for the practice of tail docking to be terminated in a way that benefits animal welfare, changes in the way pigs are housed and managed may first be required.

Direct access in the UK: what do dentists really think?

OBJECTIVE: To investigate dentists' views on the likely impact of direct access (DA), the clinical competence of hygienists and therapists to work autonomously and possible predictors of such views. DESIGN: Random survey of registered dentists. SETTING: UK, 2014. SUBJECTS AND METHODS: A random sample of UK-based dentists registered with the General Dental Council (GDC). A unique-access online questionnaire was developed, with a paper alternative. Email and postal reminders were sent. MAIN OUTCOME MEASURES: Measures of positive/negative views regarding the impact of DA and clinical competence of hygienists and therapists to work without a dentist's prescription. RESULTS: One hundred and fifty-nine responded (response rate: 27%), 78 (49.1%) of whom were female. No significant sources of response bias were identified. While 122 (77%) had not undergone joint training with dental hygienists or therapists at the undergraduate level, 98 (62.4%) currently worked with a hygienist and 33 (21.0%) with a therapist. Eighty-three (53.2%) disagreed with the GDC decision regarding DA for hygienists, and 94 (59.1%) felt the same regarding therapists. Concern was greatest in respect to diagnosis, treatment planning and restorations. Comments were predominantly negative and reflected concerns over patient safety, what was seen as hygienists' and therapists' inadequate training or expertise, the undermining of the dentist's role, service delivery, the reform being poorly planned, implemented or being a cost-cutting exercise. Experience of teamwork was not predictive of positive/negative views. CONCLUSIONS: Response was low, thus posing a potential threat to the study's representativeness. Many dentists had concerns and reservations about DA which were unrelated to teamwork experience. The dissemination of information on curricula and scope of practice may help allay such concerns, as may a greater emphasis on joint training at both the undergraduate level and within continuing professional development programmes.

The clinical relevance and newsworthiness of NIHR HTA-funded research: a cohort study.

OBJECTIVE: To assess the clinical relevance and newsworthiness of the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme funded reports. STUDY DESIGN: Retrospective cohort study. SETTING: The cohort included 311 NIHR HTA Programme funded reports publishing in HTA in the period 1 January 2007-31 December 2012. The McMaster Online Rating of Evidence (MORE) system independently identified the clinical relevance and newsworthiness of NIHR HTA publications and non-NIHR HTA publications. The MORE system involves over 4000 physicians rating publications on a scale of relevance (the extent to which articles are relevant to practice) and a scale of newsworthiness (the extent to which articles contain news or something clinicians are unlikely to know). MAIN OUTCOME MEASURES: The proportion of reports published in HTA meeting MORE inclusion criteria and mean average relevance and newsworthiness ratings were calculated and compared with publications from the same studies publishing outside HTA and non-NIHR HTA funded publications. RESULTS: 286/311 (92.0%) of NIHR HTA reports were assessed by MORE, of which 192 (67.1%) passed MORE criteria. The average clinical relevance rating for NIHR HTA reports was 5.48, statistically higher than the 5.32 rating for non-NIHR HTA publications (mean difference=0.16, 95% CI 0.04 to 0.29, p=0.01). Average newsworthiness ratings were similar between NIHR HTA reports and non-NIHR HTA publications (4.75 and 4.70, respectively; mean difference=0.05, 95% CI -0.18 to 0.07, p=0.402). NIHR HTA-funded original research reports were statistically higher for newsworthiness than reviews (5.05 compared with 4.64) (mean difference=0.41, 95% CI 0.18 to 0.64, p=0.001). CONCLUSIONS: Funding research of clinical relevance is important in maximising the value of research investment. The NIHR HTA Programme is successful in funding projects that generate outputs of clinical relevance.

Cost effectiveness of caspofungin vs. voriconazole for empiric therapy in Turkey.

Invasive fungal infections from febrile neutropenia are associated with significant cost and mortality. The mainstay of treatment has been liposomal amphotericin B, however, echinocandins and azoles have shown promise as alternative treatments. Data on clinical efficacy exist, however, data incorporating pharmacoeconomic considerations are required in Turkey. The aim of this study was to investigate the cost effectiveness of caspofungin vs. voriconazole in empiric treatment of febrile neutropenia in Turkey. A decision analytic model was utilised, built upon two randomised-controlled trials and supplemented with expert panel input from clinicians in Turkey. A five-point composite outcome measure was utilised and sensitivity analyses were performed to demonstrate the robustness of the model. The base case scenario resulted in caspofungin being preferred by TL2,533, TL29,256 and TL2,536 per patient treated, successfully treated patient and patient survival, respectively (approx. USD1414, 16 328 and 1415); sensitivity analyses did not change the outcome. Monte Carlo simulation highlighted a 78.8% chance of favouring caspofungin. The result was moderately sensitive to treatment duration and acquisition cost of the antifungal agents compared. This is the first pharmacoeconomic study comparing caspofungin to voriconazole within Turkey, resulting in an advantage towards caspofungin. The study will aid in formulary decision-making based on the clinical and economic consequences of each agent in the Turkish health care setting.

Direct access to DCPs: what are the potential risks and benefits?

The decision by the General Dental Council (GDC) in March 2013 to remove the requirement for a patient to first see a dentist before any treatment by a dental care professional, has been seen by some as controversial. The GDC has stated patient safety is the utmost priority and a literature review on direct access in dental and other healthcare fields was commissioned by the GDC in April 2012. The review considered whether any expansion of direct access would involve increased risk to patients, either by treatment or through failure to recognise and refer problems outside DCPs' clinical remit. This paper is an edited version of the results of that literature review.

Pharmacoeconomic evaluation of caspofungin versus liposomal amphotericin B in empirical treatment of invasive fungal infections in Turkey.

Invasive fungal infections (IFIs) are a major concern within healthcare systems. This pharmacoeconomic study evaluated the use of caspofungin (CAS) versus liposomal amphotericin B (L-AmB) in the empirical treatment of IFIs within the Turkish healthcare system. A decision-analytic model was adopted, utilising data from a randomised, non-inferiority clinical trial and a panel of clinical experts in Turkey. A five-point composite outcome measure was used to evaluate both agents. Sensitivity analyses were performed. In the base-case scenario, CAS was preferred over L-AmB by Turkish Lira (TL) 3961 per patient treated, TL 12 904 per successfully treated patient and TL 3972 per death averted. One-way sensitivity analysis did not change the study outcome. Monte Carlo simulation concluded a 71.0% chance of the outcome favouring CAS. The results were most sensitive to changes in length of stay. This is the first economic evaluation of the empirical treatment of IFIs in Turkey and suggests that CAS is more cost effective than L-AmB.

Publication rate for funded studies from a major UK health research funder: a cohort study.

OBJECTIVES: This study aimed to investigate what percentage of National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme-funded projects have published their final reports in the programme's journal HTA and to explore reasons for non-publication. DESIGN: Retrospective cohort study. SETTING: Failure to publish findings from research is a significant area of research waste. It has previously been suggested that potentially over 50% of studies funded are never published. PARTICIPANTS: All NIHR HTA projects with a planned submission date for their final report for publication in the journal series on or before 9 December 2011 were included. PRIMARY AND SECONDARY OUTCOME MEASURES: The projects were classified according to the type of research, whether they had been published or not; if not yet published, whether they would be published in the future or not. The reasons for non-publication were investigated. RESULTS: 628 projects were included: 582 (92.7%) had published a monograph; 19 (3%) were expected to publish a monograph; 13 (2.1%) were discontinued studies and would not publish; 12 (1.9%) submitted a report which did not lead to a publication as a monograph; and two (0.3%) did not submit a report. Overall, 95.7% of HTA studies either have published or will publish a monograph: 94% for those commissioned in 2002 or before and 98% for those commissioned after 2002. Of the 27 projects for which there will be no report, the majority (21) were commissioned in 2002 or before. Reasons why projects failed to complete included failure to recruit; issues concerning the organisation where the research was taking place; drug licensing issues; staffing issues; and access to data. CONCLUSIONS: The percentage of HTA projects for which a monograph is published is high. The advantages of funding organisations requiring publication in their own journal include avoidance of publication bias and research waste.

The impact of General Dental Council registration and continuing professional development on UK dental care professionals: (2) dental technicians.

OBJECTIVE: To investigate the impact of General Dental Council (GDC) registration and mandatory CPD on dental technicians' views, job satisfaction and intention to leave the profession. DESIGN: Postal/online survey, conducted in parallel with a survey of dental nurses. SETTING: UK private and NHS practices, community services, dental hospitals. SUBJECTS AND METHODS: Representative sample of GDC registrants. MAIN OUTCOME MEASURES: job satisfaction; intention to leave profession (dependent variable in regression analysis). RESULTS: 605 were sampled: 40 were ineligible (left the register in July 2011, re-qualified in another dental care profession, shared a practice address with another selected DT); 193 responded (response rate 34%). 22% were female (mean age 38.2 years) and 78% male (mean age 49.4 years). The general principle of registration was endorsed by 52%, and compulsory registration by 54%, but the fee level by only 13%. Most technicians felt that registration had had either no effect or a negative effect on their view of their career (80%), role (78%) or status within the dental team (85%), and 66% did not agree that training helped them to do their job better. Fifty-one percent were not satisfied with their job and 20% intended to leave the profession. Intention to leave was predicted by greater dissatisfaction with remuneration. CONCLUSIONS: Criticisms regarding the cost and relevance of registration and the cost, relevance and accessibility of CPD, coupled with potentially high level of attrition from the profession, suggest a review of the fee and salary structure and greater support for CPD is warranted.

The impact of General Dental Council registration and continuing professional development on UK dental care professionals: (1) dental nurses.

OBJECTIVE: To investigate the impact of GDC registration and mandatory CPD on dental nurses' views, job satisfaction and intention to leave. DESIGN: Postal/online survey, conducted in parallel with a survey of dental technicians. SETTING: UK private and NHS practices, community services, dental hospitals. SUBJECTS AND METHODS: Representative sample of General Dental Council registrants. MAIN OUTCOME MEASURES: Job satisfaction; intention to leave profession (dependent variable in regression analysis). RESULTS: Eleven were ineligible (left profession, moved abroad); 267 (44% of those eligible) responded, all female. Respondents' mean age was 38.2 years (sd 10.74). The general principle of registration was endorsed by 67%, and compulsory registration by 51%, but the fee level by only 6%. Most nurses did not feel that registration had affected their view of dental nursing as a career (56%), their role (74%) or status (86%) within the dental team, or that CPD helped them to do their job better (76%). Fifty-six percent were not satisfied with their job, and 22% intended to leave the profession. Intention to leave was predicted by younger age and greater dissatisfaction with physical working conditions and opportunities to progress. CONCLUSIONS: Widely held criticisms regarding the costs and relevance of registration and CPD coupled with a potentially high level of attrition from the profession suggest a review of the fee and salary structure and greater financial support for CPD is warranted.

The impact of health checks for people with intellectual disabilities: a systematic review of evidence.

BACKGROUND: Health checks for people with intellectual disabilities (ID) have been recommended as one component of health policy responses to the poorer health of people with ID. This review summarises evidence on the impact of health checks on the health and well-being of people with ID. METHODS: Electronic literature searches and email contacts were used to identify literature relevant to the impact of health checks for people with ID. RESULTS: A total of 38 publications were identified. These involved checking the health of over 5000 people with ID from a range of countries including a full range of people with ID. Health checks consistently led to detection of unmet health needs and targeted actions to address health needs. CONCLUSIONS: Health checks are effective in identifying previously unrecognised health needs, including life-threatening conditions. Future research should consider strategies for optimising the cost-effectiveness or efficiency of health checks.

Developing a non-medical prescribers' peer supervision group.

This article describes the effect and outcomes of a non-medical prescribers' peer supervision group in a secondary care mental health and learning disabilities trust two years after its inception. The article highlights how the group has encouraged networking and innovation, which have helped to develop and promote non-medical prescribing in the trust.

Childsmile: the national child oral health improvement programme in Scotland. Part 1: Establishment and development.

This paper is the first of two reviewing the Childsmile programme. It sets out to describe the development and implementation of this national oral health improvement programme for children in Scotland over its initial three-year period (January 2006 to December 2008) and into its second phase of development. It outlines the context in which the initiative was conceived, the initial development of its various components, and how monitoring and evaluation are shaping the delivery and direction of the programme.

Childsmile: the national child oral health improvement programme in Scotland. Part 2: Monitoring and delivery.

This paper, the second of two reviewing the Childsmile programme, describes monitoring arrangements and summarises monitoring data covering the period 2006-2009. By mid-2009, around 28,000 infants in deprived areas of the West of Scotland had been given caries risk assessments by Health Visitors; 14,000 were enrolled with 142 Childsmile practices or clinics; and over 10,000 had begun making practice visits. The Childsmile Nursery and School programmes had provided 28,000 fluoride varnish treatments to nursery and primary school children. Daily supervised toothbrushing and distribution of oral health packs covered almost 100% of nursery schools and P1 and P2 classes in primary schools in the most deprived areas of Scotland. Feedback of monitoring information to programme managers is used to identify any variation or shortfall in programme coverage and delivery.