Living life in limbo: experiences of healthcare professionals during the HCPC fitness to practice investigation process in the UK.

BACKGROUND: It is the responsibility of healthcare regulators to ensure healthcare professionals remain fit for practice in healthcare settings. If there are concerns about an individual healthcare professional they may undergo a fitness to practice investigation. This process is known to be hugely stressful for doctors and social workers, but little is known about the impact of this experience on other professions. This study explores the experiences of registrants going through the process of being reported to the UK's Health and Care Professions Council (HCPC) and attending fitness to practice (FTP) hearings. We discuss the implications of this process on registrants' wellbeing and, from our findings, present recommendations based on registrants experiences. In doing so we articulate the structural processes of the HCPC FTP process and the impact this has on individuals. METHODS: This study uses semi-structured interviews and framework analysis to explore the experiences of 15 registrants who had completed the FTP process. Participants were sampled for maximum variation and were selected to reflect the range of possible processes and outcomes through the FTP process. RESULTS: The psychological impact of undergoing a FTP process was significant for the majority of participants. Their stories described influences on their wellbeing at both a macro (institutional/organisational) and micro (individual) level. A lack of information, long length of time for the process and poor support avenues were macro factors impacting on the ability of registrants to cope with their experiences (theme 1). These macro factors led to feelings of powerlessness, vulnerability and threat of ruin for many registrants (theme 2). Suggested improvements (theme 3) included better psychological support (e.g. signposting or provision); proportional processes to the incident (e.g. mediation instead of hearings); and taking context into account. CONCLUSIONS: Findings suggest that improvements to both the structure and conduct of the FTP process are warranted. Implementation of better signposting for support both during and after a FTP process may improve psychological wellbeing. There may also be value in considering alternative ways of organising the FTP process to enable greater consideration of and flexibility for registrants' context and how they are investigated.

Surveillance systems evaluation: a systematic review of the existing approaches.

BACKGROUND: Regular and relevant evaluations of surveillance systems are essential to improve their performance and cost-effectiveness. With this in mind several organizations have developed evaluation approaches to facilitate the design and implementation of these evaluations. METHODS: In order to identify and to compare the advantages and limitations of these approaches, we implemented a systematic review using the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). RESULTS: After applying exclusion criteria and identifying other additional documents via citations, 15 documents were retained. These were analysed to assess the field (public or animal health) and the type of surveillance systems targeted; the development process; the objectives; the evaluation process and its outputs; and the attributes covered. Most of the approaches identified were general and provided broad recommendations for evaluation. Several common steps in the evaluation process were identified: (i) defining the surveillance system under evaluation, (ii) designing the evaluation process, (iii) implementing the evaluation, and (iv) drawing conclusions and recommendations. CONCLUSIONS: A lack of information regarding the identification and selection of methods and tools to assess the evaluation attributes was highlighted; as well as a lack of consideration of economic attributes and sociological aspects.

Use of spatiotemporal analysis of laboratory submission data to identify potential outbreaks of new or emerging diseases in cattle in Great Britain.

BACKGROUND: New and emerging diseases of livestock may impact animal welfare, trade and public health. Early detection of outbreaks can reduce the impact of these diseases by triggering control measures that limit the number of cases that occur. The aim of this study was to investigate whether prospective spatiotemporal methods could be used to identify outbreaks of new and emerging diseases in scanning surveillance data. SaTScan was used to identify clusters of unusually high levels of submissions where a diagnosis could not be reached (DNR) using different probability models and baselines. The clusters detected were subjected to a further selection process to reduce the number of false positives and a more detailed epidemiological analysis to ascertain whether they were likely to represent real outbreaks. RESULTS: 187,925 submissions of clinical material from cattle were made to the Regional Laboratory of the Veterinary Laboratories Agency (VLA) between 2002 and 2007, and the results were stored on the VLA FarmFile database. 16,925 of these were classified as DNRs and included in the analyses. Variation in the number and proportion of DNRs was found between syndromes and regions, so a spatiotemporal analysis for each DNR syndrome was done. Six clusters were identified using the Bernoulli model after applying selection criteria (e.g. size of cluster). The further epidemiological analysis revealed that one of the systemic clusters could plausibly have been due to Johne's disease. The remainder were either due to misclassification or not consistent with a single diagnosis. CONCLUSIONS: Our analyses have demonstrated that spatiotemporal methods can be used to detect clusters of new or emerging diseases, identify clusters of known diseases that may not have been diagnosed and identify misclassification in the data, and highlighted the impact of data quality on the ability to detect outbreaks. Spatiotemporal methods should be used alongside current temporal methods for analysis of scanning surveillance data. These statistical analyses should be followed by further investigation of possible outbreaks to determine whether cases have common features suggesting that these are likely to represent real outbreaks, or whether issues with the collection or processing of information have resulted in false positives.

Improving the effectiveness of cancer multidisciplinary team meetings: analysis of a national survey of MDT members' opinions about streamlining patient discussions.

Background: Cancer is diagnosed and managed by multidisciplinary teams (MDTs) in the UK and worldwide, these teams meet regularly in MDT meetings (MDMs) to discuss individual patient treatment options. Rising cancer incidence and increasing case complexity have increased pressure on MDMs. Streamlining discussions has been suggested as a way to enhance efficiency and to ensure high-quality discussion of complex cases. Methods: Secondary analysis of quantitative and qualitative data from a national survey of 1220 MDT members regarding their views about streamlining MDM discussions. Results: The majority of participants agreed that streamlining discussions may be beneficial although variable interpretations of 'streamlining' were apparent. Agreement levels varied significantly by tumour type and occupational group. The main reason for opposing streamlining were concerns about the possible impact on the quality and safety of patient care. Participants suggested a range of alternative approaches for improving efficiency in MDMs in addition to the use of treatment protocols and pre-MDT meetings. Conclusions: This work complements previous analyses in supporting the development of tumour-specific guidance for streamlining MDM discussions considering a range of approaches. The information provided about the variation in opinions between MDT for different tumour types will inform the development of these guidelines. The evidence for variation in opinions between those in different occupational groups and the reasons underlying these opinions will facilitate their implementation. The impact of any changes in MDM practices on the quality and safety of patient care requires evaluation.

The RISKSUR EVA tool (Survtool): A tool for the integrated evaluation of animal health surveillance systems.

Information about infectious diseases at the global level relies on effective, efficient and sustainable national and international surveillance systems. Surveillance systems need to be regularly evaluated to ensure their performance, the quality of the data and information provided, as well as to allocate resources efficiently. Currently available frameworks for evaluation of surveillance systems in animal or human health often treat technical, process and socio-economic aspects separately instead of integrating them. The surveillance evaluation (EVA) tool, a support tool for the evaluation of animal health surveillance systems, was developed to provide guidance for integrated evaluation of animal health surveillance including economic evaluation. The tool was developed by international experts in surveillance and evaluation in an iterative process of development, testing and revision taking into account existing frameworks and guidance, scientific literature and expert opinion. The EVA tool encompasses a web interface for users to develop an evaluation plan, a Wiki classroom to provide theoretical information on all required concepts and a generic evaluation work plan to facilitate implementation and reporting of outputs to decision makers. The tool was tested by planning and conducting epidemiological and economic evaluations of surveillance for classical and African swine fever, bovine virus diarrhoea, avian influenza, and Salmonella Dublin in five European countries. These practical applications highlighted the importance of a comprehensive evaluation approach to improve the quality of the evaluation outputs (economic evaluation; multiple attributes assessment) and demonstrated the usefulness of the guidance provided by the EVA tool. At the same time they showed that comprehensive evaluations might be constrained by practical issues (e.g. confidentiality concerns, data availability) and resource scarcity. In the long term, the EVA tool is expected to increase professional evaluation capacity and help optimising animal health surveillance system efficiency and resource allocation for both public and private actors of the surveillance systems.

Vector-borne disease surveillance in livestock populations: A critical review of literature recommendations and implemented surveillance (BTV-8) in five European countries.

Preparedness against vector-borne threats depends on the existence of a long-term, sustainable surveillance of vector-borne disease and their relevant vectors. This work reviewed the availability of such surveillance systems in five European countries (Denmark, France, The Netherlands, Sweden and United Kingdom, part of the CoVetLab network). A qualitative assessment was then performed focusing on surveillance directed particularly to BTV-8. Information regarding surveillance activities were reviewed for the years 2008 and 2012. The results were then complemented with a critical scoping review of the literature aimed at identifying disease surveillance strategies and methods that are currently suggested as best suited to target vector-borne diseases in order to guide future development of surveillance in the countries in question. Passive surveillance was found to be efficient for early detection of diseases during the early phase of introduction into a free country. However, its value diminished once the disease has been established in a territory. Detection of emerging diseases was found to be very context and area specific, and thus active surveillance designs need to take the available epidemiological, ecological and entomological information into account. This was demonstrated by the effectiveness of the bulk milk surveillance in detecting the first case in Sweden, highlighting the need for output based standards to allow the most effective, context dependent, surveillance strategies to be used. Preparedness was of fundamental importance in determining the timeliness of detection and control in each country and that this in turn was heavily influenced by knowledge of emerging diseases in neighboring countries. Therefore it is crucial to share information on outbreaks between researchers and decision-makers and across borders continuously in order to react timely in case of an outbreak. Furthermore, timely reaction to an outbreak was heavily influenced by availability of control measures (vaccines), which is also strengthened if knowledge is shared quickly between countries. The assessment of the bluetongue surveillance in the affected countries showed that the degree of voluntary engagement varied, and that it is important to engage the public by general awareness and dissemination of results. The degree of engagement will also aid in establishing a passive surveillance system.

Prevalence of scrapie infection in Great Britain: interpreting the results of the 1997-1998 abattoir survey.

An accurate estimate of the prevalence of scrapie infection in the Great Britain (GB) sheep flock is essential when assessing any potential risk to human health through exposure to sheep transmissible spongiform encephalopathies (TSEs). One method for assessing the prevalence is to sample sheep intended for human consumption using a diagnostic test capable of detecting infected animals prior to the onset of clinical signs. An abattoir survey conducted in Great Britain in 1997-1998 tested brain samples from 2809 apparently healthy sheep of which none was found to be positive for scrapie by histopathology or immunohistochemistry (IHC) although 10 were positive for scrapie-associated fibrils (SAF). Subsequently, the tonsils from a subset of the animals sampled were examined using IHC, one of which tested positive. To interpret these results we use a likelihood-based approach, which accounts for the variation in the prevalence of infection with age and test sensitivity and specificity with stage of infection. Combining the results for all of the diagnostic tests yields an estimate of the prevalence of scrapie infection in the GB sheep flock of 0.22% (95% confidence interval: 0.01-0.97%). Moreover, our analysis suggests that all of the diagnostic tests used are very specific (greater than 99%). Indeed, only SAF detection yields a specificity estimate of less than 100%, which helps to account for the high number of samples found to be positive for SAF.

Evidence for maternal transmission of scrapie in naturally affected flocks.

It has been known for many years that the offspring of scrapie affected ewes are at increased risk of developing scrapie but whether this is simply the result of an increased genetic susceptibility or transmission of infection has always been unclear. To contribute to clarify this we analysed the data collected in a detailed study of scrapie occurrence in a number of naturally affected commercial sheep flocks in Great Britain (GB) to investigate the association between PrP genotype and parental scrapie status and the incidence of scrapie. Our analyses confirmed the strong association between PrP genotype and the incidence of scrapie found in previous studies and a low incidence of scrapie in animals carrying the ARR allele and a high risk in homozygous VRQ animals. However, we also demonstrate an increased incidence of scrapie in the offspring of scrapie affected ewes controlling for the confounding effect of PrP genotype, but no increased scrapie incidence in the offspring of scrapie affected sires. Our results suggest that some of the increased incidence of scrapie in the offspring of scrapie affected ewes is the result of transmission of infection from mother to offspring. Our results confirm that a breeding policy aimed at decreasing the genetic susceptibility of the population should decrease the incidence of scrapie and that removing the offspring of scrapie affected animals from affected flocks could contribute to the control of this disease.