A picture of health: determining the core population served by an urban NHS hospital trust and understanding the key health needs.

BACKGROUND: NHS hospitals do not have clearly defined geographic populations to whom they provide care, with patients able to attend any hospital. Identifying a core population for a hospital trust, particularly those in urban areas where there are multiple providers and high population churn, is essential to understanding local key health needs especially given the move to integrated care systems. This can enable effective planning and delivery of preventive interventions and community engagement, rather than simply treating those presenting to services. In this article we describe a practical method for identifying a hospital's catchment population based on where potential patients are most likely to reside, and describe that population's size, demographic and social profile, and the key health needs. METHODS: A 30% proportional flow method was used to identify a catchment population using an acute hospital trust in West London as an example. Records of all hospital attendances between 1st April 2017 and 31st March 2018 were analysed using Hospital Episode Statistics. Any Lower Layer Super Output Areas where 30% or more of residents who attended any hospital for care did so at the example trust were assigned to the catchment area. Publicly available local and national datasets were then applied to identify and describe the population's key health needs. RESULTS: A catchment comprising 617,709 people, of an equal gender-split (50.4% male) and predominantly working age (15 to 64 years) population was identified. Thirty nine point six percent of residents identified as being from Black and Minority Ethnic (BAME) groups, a similar proportion that reported being born abroad, with over 85 languages spoken. Health indicators were estimated, including: a healthy life expectancy difference of over twenty years; bowel cancer screening coverage of 48.8%; chlamydia diagnosis rates of 2,136 per 100,000; prevalence of visible dental decay among five-year-olds of 27.9%. CONCLUSIONS: We define a blueprint by which a catchment can be defined for a hospital trust and demonstrate the value a hospital-view of the local population could provide in understanding local health needs and enabling population-level health improvement interventions. While an individual approach allows tailoring to local context and need, there could be an efficiency saving were such public health information made routinely and regularly available for every NHS hospital.

What health inequalities exist in access to, outcomes from and experience of treatment for lung cancer? A scoping review.

OBJECTIVES: Lung cancer (LC) continues to be the leading cause of cancer-related deaths and while there have been significant improvements in overall survival, this gain is not equally distributed. To address health inequalities (HIs), it is vital to identify whether and where they exist. This paper reviews existing literature on what HIs impact LC care and where these manifest on the care pathway. DESIGN: A systematic scoping review based on Arksey and O'Malley's five-stage framework. DATA SOURCES: Multiple databases (EMBASE, HMIC, Medline, PsycINFO, PubMed) were used to retrieve articles. ELIGIBILITY CRITERIA: Search limits were set to retrieve articles published between January 2012 and April 2022. Papers examining LC along with domains of HI were included. Two authors screened papers and independently assessed full texts. DATA EXTRACTION AND SYNTHESIS: HIs were categorised according to: (a) HI domains: Protected Characteristics (PC); Socioeconomic and Deprivation Factors (SDF); Geographical Region (GR); Vulnerable or Socially Excluded Groups (VSG); and (b) where on the LC pathway (access to, outcomes from, experience of care) inequalities manifest. Data were extracted by two authors and collated in a spreadsheet for structured analysis and interpretation. RESULTS: 41 papers were included. The most studied domain was PC (32/41), followed by SDF (19/41), GR (18/41) and VSG (13/41). Most studies investigated differences in access (31/41) or outcomes (27/41), with few (4/41) exploring experience inequalities. Evidence showed race, rural residence and being part of a VSG impacted the access to LC diagnosis, treatment and supportive care. Additionally, rural residence, older age or male sex negatively impacted survival and mortality. The relationship between outcomes and other factors (eg, race, deprivation) showed mixed results. CONCLUSIONS: Findings offer an opportunity to reflect on the understanding of HIs in LC care and provide a platform to consider targeted efforts to improve equity of access, outcomes and experience for patients.

Oral health promotion in acute hospital setting: a quality improvement programme.

Tooth extraction is the most common hospital procedure for children aged 6-10 years in England. Tooth decay is almost entirely preventable and is inequitably distributed across the population: it can cause pain, infection, school absences and undermine overall health status.An oral health programme (OHP) was delivered in a hospital setting, comprising: (1) health promotion activities; (2) targeted supervised toothbrushing (STB) and (3) staff training. Outcomes were measured using three key performance indicators (KPI1: percentage of children/families seeing promotional material; KPI2: number of children receiving STB; KPI3: number of staff trained) and relevant qualitative indicators. Data were collected between November 2019 and August 2021 using surveys and data from the online booking platform.OHP delivery was impacted by COVID-19, with interventions interrupted, reduced, eliminated or delivered differently (eg, in-person training moved online). Despite these challenges, progress against all KPIs was made. 93 posters were deployed across the hospital site, along with animated video 41% (233/565) of families recalled seeing OHP materials across the hospital site (KPI1). 737 children received STB (KPI2), averaging 35 children/month during the active project. Following STB, 96% participants stated they learnt something, and 94% committed to behaviour change. Finally, 73 staff members (KPI3) received oral health training. All people providing feedback (32/32) reported learning something new from the training session, with 84% (27/32) reporting that they would do things differently in the future.Results highlight the importance of flexibility and resilience when delivering QI projects under challenging conditions or unforeseen circumstances. While results suggest that hospital-based OHP is potentially an effective and equitable way to improve patient, family and staff knowledge of good oral health practices, future work is needed to understand if and how patients and staff put into practice the desired behaviour change and what impact this may have on oral health outcomes.

The impact of a free older persons' bus pass on active travel and regular walking in England.

OBJECTIVES: We assessed the potential public health benefit of the National Bus Pass, introduced in 2006, which permits free local bus travel for older adults (≥ 60 years) in England. METHODS: We performed regression analyses with annual data from the 2005-2008 National Travel Survey. Models assessed associations between being a bus pass holder and active travel (walking, cycling, and use of public transport), use of buses, and walking 3 or more times per week. RESULTS: Having a free pass was significantly associated with greater active travel among both disadvantaged (adjusted odds ratio [AOR] = 4.06; 95% confidence interval [CI] = 3.35, 4.86; P < .001) and advantaged groups (AOR = 4.72; 95% CI = 3.99, 5.59; P < .001); greater bus use in both disadvantaged and advantaged groups (AOR = 7.03; 95% CI = 5.53, 8.94; P < .001 and AOR = 7.11; 95% CI = 5.65, 8.94; P < .001, respectively); and greater likelihood of walking more frequently in the whole cohort (AOR = 1.15; 95% CI = 1.07, 1.12; P < .001). CONCLUSIONS: Public subsidies enabling free bus travel for older persons may confer significant population health benefits through increased incidental physical activity.

Smoking, SARS-CoV-2 and COVID-19: A review of reviews considering implications for public health policy and practice.

INTRODUCTION: There has been significant speculation regarding the association between the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pathogen, coronavirus disease (COVID-19) and smoking. We provide an overview of the available literature regarding the association between smoking, risk of SARS-CoV-2 infection, and risk of severe COVID-19 and poor clinical outcomes, with the aim of informing public health policy and practice, particularly in England. METHODS: Publications were identified utilising a systematic search approach on PUBMED and Google Scholar. Publications presenting a systematic review or meta-analysis considering the association between smoking and SARS-COV-2 infection or COVID-19 outcomes were included. RESULTS: Eight studies were identified. One considered the relationship between smoking and the probability of SARS-CoV-2 infection, three considered the association between COVID-19 hospitalisation and smoking history, and six reviewed the association between smoking history and development of severe COVID-19. One study specifically investigated the risk of mortality. The studies considering risk of severe disease indicate that there is a significant association between COVID-19 and current or ever smoking. CONCLUSIONS: This is a rapidly evolving topic. Current analysis remains limited due to the quality of primary data, although, early results indicate an association between smoking and COVID-19 severity. We highly recommend public health messaging to continue focusing on smoking cessation efforts.

Health care utilisation under the 30-Baht Scheme among the urban poor in Mitrapap slum, Khon Kaen, Thailand: a cross-sectional study.

BACKGROUND: In 2001, the Government of Thailand introduced a universal coverage scheme with the aim of ensuring equitable health care access for even the poorest citizens. For a flat user fee of 30 Baht per consultation, or for free for those falling into exemption categories, every scheme participant may access registered health services. The exemption categories include children under 12 years of age, senior citizens aged 60 years and over, the very poor, and volunteer health workers. The functioning of these exemption mechanisms and the effect of the scheme on health service utilisation among the poor is controversial. METHODS: This cross-sectional study investigated the prevalence of 30-Baht Scheme registration and subsequent self-reported health service utilisation among an urban poor population in the Teparuk community within the Mitrapap slum in Khon Kaen city, northeastern Thailand. Furthermore, the effectiveness of the exemption mechanisms in reaching the very poor and the elderly was examined. Factors for users' choice of health facilities were identified. RESULTS: Overall, the proportion of the Teparuk community enrolled with the 30-Baht Scheme was high at 86%, with over one quarter of these exempted from paying the consultation fee. User fee exemption was significantly more frequent among households with an above-poverty-line income (64.7%) compared to those below the poverty line (35.3%), chi2 (df) = 5.251 (1); p-value = 0.018. In addition, one third of respondents over 60 years of age were found to be still paying user fees. Self-reported use of registered medical facilities in case of illness was stated to be predominantly due to the service being available through the scheme, with service quality not a chief consideration. Overall consumer satisfaction was high, especially among those not required to pay the 30 Baht user fee. CONCLUSION: Whilst the 30-Baht Scheme seems to cover most of the poor population of Mitrapap slum in Khon Kaen, the user fee exemption mechanism only works partially with regard to reaching the poorest and exempting senior citizens. Service utilisation and satisfaction are highest amongst those who are fee-exempt. Service quality was not an important factor influencing choice of health facility. Ways should be sought to improve the effectiveness of the current exemption mechanisms.

English National Health Service's savings plan may have helped reduce the use of three 'low-value' procedures.

The pressure to contain health expenditures is unprecedented. In England a flattening of the health budget but increasing demand led the National Health Service (NHS) to seek reductions in health expenditures of 17 percent over four years. The spending cuts were to be achieved through improvements in service quality and efficiency, including reducing the use of ineffective, overused, or inappropriate procedures. However, the NHS left it to the local commissioning (or funding) organizations, known as primary care trusts, to determine what steps to take to reduce spending. To assess whether the initiative had an impact, we examined six low-value procedures: spinal surgery for lower back pain, myringotomy to relieve eardrum pressure, inguinal hernia repair, cataract removal, primary hip replacement, and hysterectomy for heavy menstrual bleeding. We found significant reductions in three of the six procedures-cataract removal, hysterectomy, and myringotomy-in the program's first year, compared to prior years' trends. However, changes in the rates of all examined procedures varied widely across commissioning organizations. Our findings highlight some of the challenges of making major budget cuts in health care. Reducing ineffective spending remains a significant opportunity for the US health care system, and the English experience may hold valuable lessons.

Application of patient-reported outcome measures (PROMs) data to estimate cost-effectiveness of hernia surgery in England.

OBJECTIVES: To demonstrate potential uses of nationally collected patient-reported outcome measures (PROMs) data to estimate cost-effectiveness of hernia surgery. DESIGN: Cost-utility model populated with national PROMs, National Reference Cost and Hospital Episodes Statistics data. SETTING: Hospitals in England that provided elective inguinal hernia repair surgery for NHS patients between 1 April 2009 and 31 March 2010. PARTICIPANTS: Patients >18 years undergoing NHS-funded elective hernia surgery in English hospitals who completed PROMs questionnaires. MAIN OUTCOME MEASURES: Change in quality-adjusted life year (QALY) following surgery; cost per QALY of surgery by acute provider hospital; health gain and cost per QALY by surgery type received (laparoscopic or open hernia repair). RESULTS: The casemix-adjusted, discounted (at 3.5%) and degraded (over 25 years) mean change in QALYs following elective hernia repair surgery is 0.826 (95% CI, 0.793-0.859) compared to a counterfactual of no treatment. Patients undergoing laparoscopic surgery show a significantly greater gain in health-related quality of life (EQ-5D index change, 0.0915; 95% CI, 0.0850-0.0979) with an estimated gain of 0.923 QALYS (95% CI, 0.859-0.988) compared to those having open repair (EQ-5D index change, 0.0806; 95% CI, 0.0771-0.0841) at 0.817 QALYS (95% CI, 0.782-0.852). The average cost of hernia surgery in England is £1554, representing a mean cost per QALY of £1881. The mean cost of laparoscopic and open hernia surgery is equivocal (£1421 vs. £1426 respectively) but laparoscopies appear to offer higher cost-utility at £1540 per QALY, compared to £1746 per QALY for open surgery. CONCLUSIONS: Routine PROMs data derived from NHS patients could be usefully analyzed to estimate health outcomes and cost-effectiveness of interventions to inform decision-making. This analysis suggests elective hernia surgery offers value-for-money, and laparoscopic repair is more clinically effective and generates higher cost-utility than open surgery.

Evaluation of clinical threshold policies for cataract surgery among English commissioners.

OBJECTIVES: To ascertain if access to cataract surgery is being restricted in England and to describe any explicit threshold criteria. METHODS: A survey of 151 local commissioners to explore their cataract surgery policy. A literature review identified research evidence about thresholds for cataract surgery. A checklist was devised and applied to the policies supplied by commissioners. RESULTS: Almost half (71/151) of commissioners were restricting access to surgery and this included patients with some capacity to benefit. There was wide variation in the scope and content of the 67 policies which were available for review. Almost all (92%) commissioners use criteria that do not reflect guidance or research evidence. CONCLUSIONS: Patients who could benefit from cataract surgery are being excluded by some commissioners. Variations in policy between commissioners results in inequalities in access.

Effective smoking cessation interventions for COPD patients: a review of the evidence.

OBJECTIVES: To review the effectiveness of smoking cessation interventions offered to chronic obstructive pulmonary disease (COPD) patients, and identify barriers to quitting experienced by them, so that a more effective service can be developed for this group. DESIGN: A rapid systematic literature review comprising computerized searches of electronic databases, hand searches and snowballing were used to identify both published and grey literature. SETTING: A review of studies undertaken in north-western Europe (defined as: United Kingdom, Ireland, France, Germany, Benelux and Nordic countries). PARTICIPANTS: COPD patients participating in studies looking at the effectiveness of smoking cessation interventions in this patient group, or exploring the barriers to quitting experienced by these patients. METHOD: Quantitative and qualitative papers were selected according to pre-specified inclusion and exclusion criteria, critically appraised, and quantitative papers scored against the NICE Levels of Evidence standardized hierarchy. MAIN OUTCOME MEASURE: Percentages of successful quitters and length of quit, assessed by self-report or biochemical analysis. Among qualitative studies, identified barriers to smoking cessation had to be explored. RESULTS: Three qualitative and 13 quantitative papers were finally selected. Effective interventions and barriers to smoking cessation were identified. Pharmacological support with Buproprion combined with counselling was significantly more efficacious in achieving prolonged abstinence than a placebo by 18.9% (95% CI 3.6-26.4%). Annual spirometry with a brief smoking cessation intervention, followed by a personal letter from a doctor, had a significantly higher ≥1 year abstinence rate at three years among COPD patient smokers, compared to smokers with normal lung function (P < 0.001; z = 3.93). Identified barriers to cessation included: patient misinformation, levels of motivation, health beliefs, and poor communication with health professionals. CONCLUSION: Despite the public health significance of COPD, there is a lack of high-quality evidence showing which smoking cessation support methods work for these patients. This review describes three effective interventions, as well as predictors of quitting success that service providers could use to improve quit rates in this group. Areas that would benefit from urgent further research are also identified.