The views of psychiatrists on proposed changes to the England and Wales Mental Health Act 1983 legislation for people with intellectual disability: A national study.

BACKGROUND: The Draft Mental Health Bill proposes removal of both intellectual disability and autism from Section 3 of the Mental Health Act for England and Wales (MHA). This would lead to people with intellectual disability (PwID) and/or autism could not be detained beyond 28 days, in the absence of diagnosed co-occurring mental illness. AIM: To obtain views of psychiatrists working with PwID in England and Wales regarding the proposed MHA changes. This study focusses specifically on the impact on PwID. METHODS: A cross-sectional online mixed methodology survey of Likert and free-text response questions was developed, to ascertain perceptions of proposed legislative changes to the MHA. A non-discriminatory exponential snowballing technique leading to non-probability sampling was used to disseminate the survey. Quantitative data was analysed using descriptive statistics, Mann-Whitney and Fisher's exact tests. Thematic analysis was conducted on free text responses. RESULTS: A total of 82 psychiatrists (33%) from approximately 250 eligible completed the survey. Nearly two-thirds (64%) reported good awareness of the proposed changes, with over half (55%) reporting disagreement with the changes. Psychiatrists working in inpatient settings for PwID reported increased awareness of the changes, less agreement with the reforms, and increased expectations of the reforms having negative unintended consequences, compared to their peers working exclusively in the community. Consultants reported greater disagreement with the changes compared to their non-consultant peers. Qualitative analysis identified five main themes: impact on diagnosis and treatment, seeking alternative options, introducing inequities, resources, and meeting holistic care goals through the Care, Education and Treatment Reviews (CETR) process. CONCLUSION: Psychiatrists working with PwID report widespread disagreement with the proposed changes to the MHA for PwID, with greater levels of disagreement among those working in inpatient services. Caution with respect to the proposed changes, and monitoring of the impact of the changes if implemented, is advised.

Using technology to encourage ward-culture change and provide individualised bladder care.

When discussing continence care in an acute hospital setting, it can be viewed as a negative subject that is a thinly veiled jab at overstretched nurses. This article takes a fresh and holistic look at continence care, identifying factors that could be causing poor care and how technology could support a change in care. This article includes suggestions on how the data collected could be used to deliver the person-centred care outcomes that may be lacking in some environments, something that one of the authors (DP) has experienced first hand. This article describes the results of a recent trial at Ysbyty Cwm Cynon (Canon Valley Hospital), NHS Wales, which looked at how continence care technology could support positive care outcomes.

Interview with inaugural Future Generations Commissioner for Wales, Sophie Howe: embedding a wellbeing approach in government.

In 2016, Wales became the first country in the world to appoint a Future Generations Commissioner - in essence a 'guardian' of the interests of future generations - under its Well-being Future Generations (Wales) Act 2015. The Act puts in place seven long-term wellbeing goals: a prosperous Wales; a resilient Wales; a more equal Wales; a healthier Wales; a Wales of cohesive communities; a Wales of vibrant culture & thriving Welsh language; and a globally responsible Wales. The Act also defines five 'ways of working' or principles that public bodies must demonstrate in decision making: thinking for the long-term, prevention; integration; collaboration; and involvement. The inaugural Commissioner, Sophie Howe, who held the role for seven years, reflects on the challenges and successes of leading transformational change to achieve a whole-of-government focus on wellbeing across policy and practice. In this interview with PHRP Editor-in-Chief Don Nutbeam, she shares some of the key lessons learned during her time in the role, including the need to embed the future generations approach in law, to set holistic, long-term goals - and to avoid blindly following measures and metrics.

Green space for public mental health: an ethnographic study of ecotherapy in Wales.

AIMS: In recent years, there has been a growing interest in the ways that human health intersects with exposure to nature. This article reports the findings of a research study investigating the experiences of people in South and West Wales who were engaged in a specific type of nature and health intervention: ecotherapy. METHODS: Ethnographic methods were used to develop a qualitative account of the experiences of participants in four specific ecotherapy projects. Data collected during fieldwork included notes from participant observations, interviews with both individuals and small groups, and documents produced by the projects. RESULTS: Findings were reported using two themes: 'smooth and striated bureaucracy' and 'escape and getting away'. The first theme focused on how participants negotiated tasks and systems related to gatekeeping, registration, record keeping, rule compliance, and evaluation. It was argued that this was experienced differently along a spectrum between striated, in which it was disruptive to time and space, and smooth, in which it was much more discrete. The second theme reported on an axiomatic perception that natural spaces represented an escape or refuge; in terms of both reconnecting with something beneficial in nature, and also disconnecting from pathological aspects of everyday life. In bringing the two themes into dialogue, it could be seen that bureaucratic practices often undermined the therapeutic sense of escape; and that this was more acutely experienced by participants from marginalised social groups. CONCLUSIONS: This article concludes by reasserting that the role of nature in human health is contested and arguing for a greater emphasis on inequities in access to good quality green and blue space. Specific interventions like ecotherapy need funding models that avoid striated bureaucratic processes, and the stress associated with these. Inclusive models of ecotherapy practice could contribute to public health goals related to population engagement with healthy environments.

Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: pragmatic, multicentre, phase 3, double blind, randomised controlled trial.

OBJECTIVE: To assess the effectiveness of oral spironolactone for acne vulgaris in adult women. DESIGN: Pragmatic, multicentre, phase 3, double blind, randomised controlled trial. SETTING: Primary and secondary healthcare, and advertising in the community and on social media in England and Wales. PARTICIPANTS: Women (≥18 years) with facial acne for at least six months, judged to warrant oral antibiotics. INTERVENTIONS: Participants were randomly assigned (1:1) to either 50 mg/day spironolactone or matched placebo until week six, increasing to 100 mg/day spironolactone or placebo until week 24. Participants could continue using topical treatment. MAIN OUTCOME MEASURES: Primary outcome was Acne-Specific Quality of Life (Acne-QoL) symptom subscale score at week 12 (range 0-30, where higher scores reflect improved QoL). Secondary outcomes were Acne-QoL at week 24, participant self-assessed improvement; investigator's global assessment (IGA) for treatment success; and adverse reactions. RESULTS: From 5 June 2019 to 31 August 2021, 1267 women were assessed for eligibility, 410 were randomly assigned to the intervention (n=201) or control group (n=209) and 342 were included in the primary analysis (n=176 in the intervention group and n=166 in the control group). Baseline mean age was 29.2 years (standard deviation 7.2), 28 (7%) of 389 were from ethnicities other than white, with 46% mild, 40% moderate, and 13% severe acne. Mean Acne-QoL symptom scores at baseline were 13.2 (standard deviation 4.9) and at week 12 were 19.2 (6.1) for spironolactone and 12.9 (4.5) and 17.8 (5.6) for placebo (difference favouring spironolactone 1.27 (95% confidence interval 0.07 to 2.46), adjusted for baseline variables). Scores at week 24 were 21.2 (5.9) for spironolactone and 17.4 (5.8) for placebo (difference 3.45 (95% confidence interval 2.16 to 4.75), adjusted). More participants in the spironolactone group reported acne improvement than in the placebo group: no significant difference was reported at week 12 (72% v 68%, odds ratio 1.16 (95% confidence interval 0.70 to 1.91)) but significant difference was noted at week 24 (82% v 63%, 2.72 (1.50 to 4.93)). Treatment success (IGA classified) at week 12 was 31 (19%) of 168 given spironolactone and nine (6%) of 160 given placebo (5.18 (2.18 to 12.28)). Adverse reactions were slightly more common in the spironolactone group with more headaches reported (20% v 12%; p=0.02). No serious adverse reactions were reported. CONCLUSIONS: Spironolactone improved outcomes compared with placebo, with greater differences at week 24 than week 12. Spironolactone is a useful alternative to oral antibiotics for women with acne. TRIAL REGISTRATION: ISRCTN12892056.

Mortality risk in adults with intellectual disabilities and epilepsy: an England and Wales case-control study.

BACKGROUND: People with epilepsy (PWE) and people with intellectual disabilities (ID) both live shorter lives than the general population and both conditions increase the risk of death further. We aimed to measure associations between certain risk factors for death in PWE and ID. METHODS: A retrospective case-control study was conducted in ten regions in England and Wales. Data were collected on PWE registered with secondary care ID and neurology services between 2017 and 2021. Prevalence rates of neurodevelopmental, psychiatric and medical diagnoses, seizure frequency, psychotropic and antiseizure medications (ASM) prescribed, and health activity (epilepsy reviews/risk assessments/care plans/compliance etc.) recorded were compared between the two groups. RESULTS: 190 PWE and ID who died were compared with 910 living controls. People who died were less likely to have had an epilepsy risk assessment but had a greater prevalence of genetic conditions, older age, poor physical health, generalized tonic-clonic seizures, polypharmacy (not ASMs) and antipsychotic use. The multivariable logistic regression for risk of epilepsy-related death identified that age over 50, medical condition prevalence, antipsychotic medication use and the lack of an epilepsy review in the last 12 months as associated with increased risk of death. Reviews by psychiatrists in ID services was associated with a 72% reduction in the odds of death compared neurology services. CONCLUSIONS: Polypharmacy and use of antipsychotics may be associated with death but not ASMs. Greater and closer monitoring by creating capable health communities may reduce the risk of death. ID services maybe more likely to provide this holistic approach.

A survey of quality-of-life tools used in the routine care of patients with multiple myeloma.

BACKGROUND: New treatment options have significantly improved the life expectancy of myeloma patients such that their cause of death is increasingly likely to be from something other than myeloma. Furthermore, the adverse effects of short- or long-term treatments as well as the disease are impacting on quality of life (QoL) for longer periods of time. Understanding people's QoL and what is important to them, is part of providing holistic care. Although QoL data has been collected for many years in myeloma studies, they have not been used to inform patient outcomes. There is growing evidence that supports the assessment of 'fitness' and consideration of QoL as part of routine myeloma care. A national survey was carried out to discover which QoL tools are currently being used in the routine care of myeloma patients, by whom and at which time point. METHODS: An online survey using SurveyMonkey was adopted for flexibility and accessibility. The link to the survey was circulated via Bloodwise, Myeloma UK and Cancer Research UK contact lists. Paper questionnaires were circulated at the UK Myeloma Forum. RESULTS: Data about practices in 26 centres were collected. This included sites across England and Wales. Three out of 26 centres collect QoL data as part of standard care. QoL tools used include EORTC QLQ-My20/24, MyPOS, FACT-BMT and Quality of Life Index. Questionnaires were completed by patients before, during or after a clinic appointment. Clinical nurse specialists calculate the scores and create a care plan. CONCLUSION: Despite growing evidence to support an holistic approach to management of myeloma patients, there is a lack of evidence to confirm that health-related QoL is being addressed in standard care. This is an area that needs further research.

Meaning of Family Reported Outcome Measure (FROM-16) severity score bands: a cross-sectional online study in the UK.

OBJECTIVE: To assign clinical meanings to the Family Reported Outcome Measure (FROM-16) scores through the development of score bands using the anchor-based approach. DESIGN AND SETTING: A cross-sectional online study recruited participants through UK-based patient support groups, research support platforms (HealthWise Wales, Autism Research Centre-Cambridge University database, Join Dementia Research) and through social service departments in Wales. PARTICIPANTS: Family members/partners (aged ≥18 years) of patients with different health conditions. INTERVENTION: Family members/partners of patients completed the FROM-16 questionnaire and a Global Question (GQ). MAIN OUTCOME MEASURE: Various FROM-16 band sets were devised as a result of mapping of mean, median and mode of the GQ scores to FROM-16 total score, and receiver operating characteristic-area under the curve cut-off values. The band set with the best agreement with GQ based on weighted kappa was selected. RESULTS: A total of 4413 family members/partners (male=1533, 34.7%; female=2858, 64.8%; Prefer not to say=16, 0.4%; other=6, 0.14%) of people with a health condition (male=1994, 45.2%; female=2400, 54.4%; Prefer not to say=12, 0.3%; other=7, 0.16%) completed the online survey: mean FROM-16 score=15.02 (range 0-32, SD=8.08), mean GQ score=2.32 (range 0-4, SD=1.08). The proposed FROM-16 score bandings are: 0-1=no effect on the quality of life of family member; 2-8=small effect on family member; 9-16=moderate effect on family member; 17-25=very large effect on family member; 26-32=extremely large effect on family member (weighted kappa=0.60). CONCLUSION: The FROM-16 score descriptor bands provide new information to clinicians about interpreting scores and score changes, allowing better-informed treatment decisions for patients and their families. The score banding of FROM-16, along with a short administration time, demonstrates its potential to support holistic clinical practice.

Beyond social prescribing-The use of social return on investment (SROI) analysis in integrated health and social care interventions in England and Wales: A protocol for a systematic review.

With increasing costs of healthcare in England and Wales following the COVID-19 pandemic, finding alternatives to traditional medical interventions is more important than ever. Social prescribing provides a way of addressing health and well-being through using non-medical methods that may help relieve costs to the NHS. Evaluating interventions, such as social prescribing, which have high social (but not easily quantifiable) value, can be problematic. Social return on investment (SROI) is a method of assigning monetary values to both social value as well as traditional assets, so provides a way of evaluating social prescribing initiatives. This protocol outlines the steps that will be taken in a systematic review of the SROI literature surrounding social prescribing-type integrated health and social care interventions based in the community in England and Wales. Online academic databases such as PubMed Central, ASSIA and Web of Science will be searched, as will grey literature sources such as Google Scholar, the Wales School for Social Prescribing Research (WSSPR) and Social Value UK. Titles and abstracts from the articles returned by the searches will be reviewed by one researcher. Those selected for full text review will be independently reviewed and compared by two researchers. Where the researchers disagree a third reviewer will help resolve any differences. Information collected will include identifying stakeholder groups, assessing the quality of SROI analyses, identifying intended and unintended changes of social prescribing interventions, and comparing social prescribing initiatives in terms of SROI costs and benefits. Quality assessment will be independently conducted on the selected papers by two researchers. The researchers will discuss to obtain consensus. Where there is disagreement, a third researcher will resolve these cases. A pre-existing quality framework will be developed and used to assess the quality of the literature. Protocol registration Prospero registration number: CRD42022318911.

Photobiomodulation in the management of oral mucositis for adult head and neck cancer patients receiving irradiation: the LiTEFORM RCT.

BACKGROUND: Oral mucositis is a debilitating and painful complication of head and neck cancer irradiation that is characterised by inflammation of the mucous membranes, erythema and ulceration. Oral mucositis affects 6000 head and neck cancer patients per year in England and Wales. Current treatments have not proven to be effective. International studies suggest that low-level laser therapy may be an effective treatment. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of low-level laser therapy in the management of oral mucositis in head and neck cancer irradiation. To identify barriers to and facilitators of implementing low-level laser therapy in routine care. DESIGN: Placebo-controlled, individually randomised, multicentre Phase III superiority trial, with an internal pilot and health economic and qualitative process evaluations. The participants, outcome assessors and therapists were blinded. SETTING: Nine NHS head and neck cancer sites in England and Wales. PARTICIPANTS: A total of 87 out of 380 participants were recruited who were aged ≥ 18 years and were undergoing head and neck cancer irradiation with ≥ 60 Gy. INTERVENTION: Random allocation (1 : 1 ratio) to either low-level laser therapy or sham low-level laser therapy three times per week for the duration of irradiation. The diode laser had the following specifications: wavelength 660 nm, power output 75 mW, beam area 1.5 cm2, irradiance 50 mW/cm2, exposure time 60 seconds and fluence 3 J/cm2. There were 20-30 spots per session. Sham low-level laser therapy was delivered in an identical manner. MAIN OUTCOME MEASURE: The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks following the start of irradiation. Higher scores indicate a worse outcome. RESULTS: A total of 231 patients were screened and, of these, 87 were randomised (low-level laser therapy arm, n = 44; sham arm, n = 43). The mean age was 59.4 years (standard deviation 8.8 years) and 69 participants (79%) were male. The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks was 33.2 (standard deviation 10) in the low-level laser therapy arm and 27.4 (standard deviation 13.8) in the sham arm. LIMITATIONS: The trial lacked statistical power because it did not meet the recruitment target. Staff and patients willingly participated in the trial and worked hard to make the LiTEFORM trial succeed. However, the task of introducing, embedding and sustaining new low-level laser therapy services into a complex care pathway proved challenging. Sites could deliver low-level laser therapy to only a small number of patients at a time. The administration of low-level laser therapy was viewed as straightforward, but also time-consuming and sometimes uncomfortable for both patients and staff, particularly those staff who were not used to working in a patient's mouth. CONCLUSIONS: This trial had a robust design but lacked power to be definitive. Low-level laser therapy is relatively inexpensive. In contrast with previous trials, some patients found low-level laser therapy sessions to be difficult. The duration of low-level laser therapy sessions is, therefore, an important consideration. Clinicians experienced in oral cavity work most readily adapt to delivering low-level laser therapy, although other allied health professionals can be trained. Blinding the clinicians delivering low-level laser therapy is feasible. There are important human resource, real estate and logistical considerations for those setting up low-level laser therapy services. FUTURE WORK: Further well-designed randomised controlled trials investigating low-level laser therapy in head and neck cancer irradiation are needed, with similar powered recruitment targets but addressing the recruitment challenges and logistical findings from this research. TRIAL REGISTRATION: This trial is registered as ISRCTN14224600. FUNDING: This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 46. See the NIHR Journals Library website for further project information.

Around 9 out of 10 head and neck cancer patients undergoing treatment experience pain, swelling and sores in their mouth (oral mucositis). This can lead to weight loss, painful ulcers, difficulty talking, eating and drinking, and even hospitalisation. Current care includes helping patients to keep their mouth and teeth clean, encouraging them to have a healthy diet and prescribing mouthwashes, painkillers and mouth-coating gels. However, these treatments give limited help in preventing or treating this condition. The LiTEFORM trial looked at whether or not low-level laser therapy could be used to prevent and treat oral mucositis. Patients were allocated to one of two arms at random: active laser or fake (sham) laser. Neither the patients nor the hospital staff knew which laser was being used. Eighty-seven people joined the study during the time allowed (44 received low-level laser therapy and 43 received sham treatment); however, this was a smaller number than the planned target of 380 people. As a result, no meaningful conclusion can be drawn from the results about whether the therapy is beneficial or cost-effective. People receiving the low-level laser therapy reported slightly more soreness in their mouth than those receiving the sham laser, but this could be down to chance. The number of participants is too small to draw conclusions about whether or not the low-level laser is helpful. Some patients found the laser treatment sessions to be difficult. Setting up a new service delivering laser therapy at the same time as cancer treatments was more complicated than originally anticipated. Problems included the scheduling of appointments, finding suitable rooms and having enough trained staff with time to deliver laser therapy. However, this study has provided us with knowledge on how best to set up a laser therapy service in the NHS as part of the cancer treatment pathway and the costs involved. These findings could help future studies looking into low-level laser therapy for those with head and neck cancer.

Data resource profile: children looked after administrative records in Wales.

Introduction: Children who are 'looked after' by the State are considered one of the most vulnerable groups in society. Being in State care is associated with poor social, educational and health outcomes. Exploring how to improve the system and better support children in care is key to improving these outcomes. When children and young people come to the attention of children's social services a significant amount of information about their care experience is routinely collected by local authorities. In Wales, routine data are captured in the 'Children Looked After' Census which is submitted annually to the Welsh Government and has recently been shared with the Secure Anonymised Information Linkage (SAIL) Databank. Method: The aim of this paper is to provide an overview of the main 'Children Looked After' Census dataset and its subsets. These datasets contain rich, situational and individual level data on children looked after, such as information on placement types, education and leaving care. We outline the strengths and limitations of the available information and how to access the data. Results: The 'Children Looked After' Census has recently been made available for research purposes and access to it will enable researchers to explore and understand at population level the journey through the care system and outcomes of leaving care. There is also the opportunity, through the SAIL Databank, for data linkage to health, education and family justice datasets, allowing research to holistically explore other factors associated with being in care. Conclusion: These data provide a rich source of information about children and young people who have been in care in Wales. They offer researchers opportunities to better understand the care system and outcomes for this within it. Findings will have important implications for making improvements in children's social care policy and practice.

National Policy Response to the United Nations Sustainable Development Goals: A Physical Activity Case Study of Wales.

BACKGROUND: Population level changes in physical activity (PA) may benefit from policy intervention. In response to the United Nations Sustainable Development Goals, Wales introduced legislation to holistically improve health and well-being, including Public Service Boards, to improve the translation of national policy into practice. METHOD: An audit of policies published by national and subnational public bodies since 2015 was conducted. Content of the policies were extracted and synthesized to determine: (1) how many policies included a PA action, (2) what the drivers of those policies were, (3) the content of the PA actions, and (4) how the PA actions aligned with the Well-being of Future Generations (Wales) Act 2015. RESULTS: Sixteen national-level documents with a PA action were published by 4 of 13 public bodies. The policies vary in terms of the clarity and specificity of the actions, the assignment of clear roles/responsibilities, and the setting of targets. Of the 19 subnational Public Service Boards well-being policies, 15 included PA actions. CONCLUSION: This audit provides a valuable example of how connections between national and subnational policy can be achieved. The appointment of Public Service Boards has supported the translation of policies into practice in Wales, and similar approaches could be utilized in other countries.

Mental health of the nursing and midwifery workforce in Wales during the COVID-19 pandemic: a cross-sectional analysis.

BACKGROUND: The mental health of the nursing and midwifery workforce in the UK became a public health concern before the COVID-19 pandemic. Poor mental health is a known factor for those considering leaving the profession, and workforce retention of younger members is crucial for the future of the sector. The aim of this study was to provide up-to-date estimates of mental wellbeing in this workforce in Wales during the COVID-19 pandemic. METHODS: We did a cross-sectional analysis of demographics, work-related information, and health data from respondents to a national online survey of registered and student nurses and midwives and health-care support workers in Wales. The survey was open between June 23 and Aug 9, 2021, and 2910 people responded (approximately 7% of the workforce). Mental wellbeing was calculated using the Short Warwick Edinburgh Mental Wellbeing Score (SWEMWBS). We measured probable clinical depression (SWEMWBS <18) and possible mild depression (SWEMWBS 18-20). We used χ2 analysis and multinomial logistic regression (adjusted for sex and staff grouping) to examine associations between age groups and mental wellbeing. FINDINGS: We analysed data from 2781 (95·6%) of 2910 respondents (129 respondents did not answer all seven SWEMWBS questions). Overall, 1622 (58·3%) of 2781 respondents had SWEMWBSs indicative of either probable clinical depression (863 [31·0%] of 2781) or possible mild depression (759 [27·3%] of 2781). Probable clinical depression was highest among those aged 18-29 years (180 [33·8%] of 532), 30-39 years (250 [35·6%] of 703), and 40-49 years (233 [33·5%] of 696). Respondents in these age groups were twice as likely to report SWEMWBSs indicative of probable clinical depression than respondents aged 60 years and older (18-29 years adjusted odds ratio [aOR] 2·38 [95% CI 1·43-3·97], p=0·0009; 30-39 years aOR 2·86 [1·77-4·64], p<0·0001; 40-49 years aOR 2·49 [1·54-4·02], p=0·0002). INTERPRETATION: This study highlights the substantial burden of poor mental wellbeing among the nursing and midwifery workforce in Wales, especially in those aged 49 years and younger. These figures, higher than previous estimates, could reflect the mental health effect of responding to the pandemic and could have long-term implications on workforce retention. FUNDING: None.

Antibiotic resistance among invasive Neisseria meningitidis isolates in England, Wales and Northern Ireland (2010/11 to 2018/19).

Invasive meningococcal disease (IMD), caused by Neisseria meningitidis, can have a fatality rate as high as 10%, even with appropriate treatment. In the UK, penicillin is administered to patients in primary care whilst third generation cephalosporins, cefotaxime and ceftriaxone, are administered in secondary care. The first-choice antibiotic for chemoprophylaxis of close contacts is ciprofloxacin, followed by rifampicin. Immunocompromised individuals are often recommended antibiotic chemoprophylaxis and vaccination due to a greater risk of IMD. Resistance to antibiotics among meningococci is relatively rare, however reduced susceptibility and resistance to penicillin are increasing globally. Resistance to third generation cephalosporins is seldom reported, however reduced susceptibility to both cefotaxime and ceftriaxone has been observed. Rifampicin resistance has been reported among meningococci, mainly following prophylaxis, and ciprofloxacin resistance, whilst uncommon, has also been reported across the globe. The Public Health England Meningococcal Reference Unit receives and characterises the majority of isolates from IMD cases in England, Wales and Northern Ireland. This study assessed the distribution of antibiotic resistance to penicillin, rifampicin, ciprofloxacin and cefotaxime among IMD isolates received at the MRU from 2010/11 to 2018/19 (n = 4,122). Out of the 4,122 IMD isolates, 113 were penicillin-resistant, five were ciprofloxacin-resistant, two were rifampicin-resistant, and one was cefotaxime-resistant. Penicillin resistance was due to altered penA alleles whilst rifampicin and ciprofloxacin resistance was due to altered rpoB and gyrA alleles, respectively. Cefotaxime resistance was observed in one isolate which had an altered penA allele containing additional mutations to those harboured by the penicillin-resistant isolates. This study identified several isolates with resistance to antibiotics used for current treatment and prophylaxis of IMD and highlights the need for continued surveillance of resistance among meningococci to ensure continued effective use.

Assessing the relationship between adverse pregnancy outcomes and area-level deprivation in Wales 2014-2019: a national population-based cross-sectional study.

OBJECTIVES: The aim of this study was to assess the relationship between deciles of area-level deprivation and seven adverse pregnancy outcomes in Wales. DESIGN: Cross-sectional analysis. SETTING: 64 699 live births in Wales from 31 March 2014 to 16 September 2019. PRIMARY OUTCOME VARIABLE: We examined each of the following seven adverse pregnancy outcomes: (1) small for gestational age (SGA); (2) large for gestational age; (3) preterm birth; (4) third-degree or fourth-degree perineal tear; (5) major postpartum haemorrhage (MPPH); (6) a lower Apgar score at 5 min and (7) emergency caesarean section. RESULTS: There was no significant association between increasing aggregate measures of area-level deprivation and the adverse pregnancy outcomes we studied. Women living in an area with greater access to services are more likely to have a baby that is SGA (1.27, 95% CI 1.11 to 1.49), have a greater likelihood of a perineal tear (1.74, 95% CI 1.15 to 2.61), are significantly less likely to have MPPH (0.79, 95% CI 0.64 to 0.96), have a baby with an Apgar score of 0.26 higher (95% CI 0.22 to 0.29) and are significantly less likely to have an emergency caesarean section (0.81, 95% CI 0.73 to 0.88). Women living in areas with higher employment (0.26, 95% CI 0.19 to 0.36) and better health (0.26, 95% CI 0.19 to 0.35) were less likely to experience perineal tear. CONCLUSIONS: There was no clear social-spatial gradient in area-level deprivation and adverse pregnancy outcomes. We found a stronger association for individual-level behavioural risk factors than area-level factors. These findings support the benefits that accessible and holistic person-centred care may bring through addressing individual behavioural risk factors. There is a need for improved data completeness and further individual-level data on risk factors such as employment and income to better understand the role which may be played by population-level policies and their pathways to affecting outcomes.

Trends in termination of pregnancy for neural tube defects in England and Wales from 2007 to 2017: Observational prospective study.

BACKGROUND/OBJECTIVE: Neural tube defects (NTDs) affect approximately 300,000 pregnancies worldwide each year. Many of these pregnancies are lost to miscarriage or termination of pregnancy. Here, we have analysed the trends of termination of pregnancy for NTDs from the national data for England and Wales. METHODS: Data for all terminations for residents in England and Wales for the period of 2007-2017 were obtained through Health and Social Act 4 (HSA4) submitted to the Department of Health. Using the ICD-10 codes, terminations for NTDs were selected for analysis. The statistical test Chi-squared was performed using SPSS-v25, where appropriate. RESULTS: In the 11-year period, there were 28,866 terminations under Ground E; of which 4425 (15.33%) had a diagnosis of NTD. The number of NTD cases increased over the time period from 308 in 2007 to 517 in 2017 (67.9%). Significant results were also seen when analysing the relationship between ethnicity, gestation and terminations where an NTD was diagnosed. CONCLUSION: With the availability of routine prenatal ultrasound, the termination for NTDs is on the rise in England and Wales, in spite of the health advice of periconceptional folic acid. This study demonstrates the need for implementation of further programmes to increase public health awareness of folic supplementation and government initiation of fortification to reduce NTDs.

Using health impact assessment (HIA) to understand the wider health and well-being implications of policy decisions: the COVID-19 'staying at home and social distancing policy' in Wales.

BACKGROUND: Health Impact Assessment (HIA) is promoted as a decision-informing tool by public health and governmental agencies. HIA is beneficial when carried out as part of policy development but is also valuable as a methodology when a policy is being implemented to identify and understand the wider health and well-being impacts of policy decisions, particularly when a decision needs to be taken rapidly to protect the population. This paper focusses on a HIA of the 'Staying at Home and Social Distancing Policy' or 'lockdown' in response to the COVID-19 pandemic in Wales conducted by the Welsh national public health institute. It describes the process and findings, captures the learning and discusses how the process has been used to better understand the wider health and well-being impacts of policy decisions beyond direct health harm. It also examines the role of public health institutes in promoting and using HIA. METHODS: A HIA was conducted following a standard HIA five step process. A literature review was undertaken alongside 15 qualitative semi-structured interviews with key stakeholders, and relevant health and demographic data were collated. The results were triangulated and analysed to form a holistic assessment of the policy decision and its impacts. RESULTS: A wide range of major health and well-being impacts of the lockdown in Wales were identified across the determinants of health, which included positive and negative social, economic, environmental and mental well-being impacts beyond the impact on direct health. Populations affected included children and young people, those on low incomes and women as well as those whose health has been directly impacted by COVID-19 such as older people. The work highlighted the benefit that HIA can bring in emphasizing impacts which can inform policy and shared learning with others. CONCLUSION: HIA is a largely underused tool to understand the impact of policy and political decisions, particularly when a decision has been taken at speed. This case study highlights how HIA provide evidence and information for advocacy and further work by public health institutes, health agencies and policy makers.

Factors influencing initiation of health behaviour conversations with patients: Cross-sectional study of nurses, midwives, and healthcare support workers in Wales.

AIM: To identify factors influencing healthcare professionals' engagement in health behaviour conversations with patients. DESIGN: Cross-sectional survey. METHODS: Between April and June 2019, an online survey of 1338 nurses, midwives and healthcare support workers was conducted. The survey assessed whether staff felt comfortable initiating health behaviour conversations with patients about five behaviours (reducing alcohol intake; stop smoking; being more active; reducing their weight; and improving their diet) and barriers to conversation initiation. Health professionals' own health-related behaviours, self-rated health and mental wellbeing, and socio-demographic characteristics were recorded. Logistic regression models were built to assess factors associated with feeling comfortable initiating health behaviour conversations for each topic. RESULT: Less than 50% of respondents reported feeling comfortable initiating health behaviour conversations with patients. Female staff, young professionals (18 to 29 years), those in lower staff grades and those with poorer health and low mental wellbeing were less likely to report feeling comfortable having health behaviour conversations across all topics. Those who did not adhere to physical activity and dietary guidelines were less likely to initiate a conversation about being more active and having a healthy diet, respectively. Not having time to discuss the topic, suitable space to hold a conversation, and feeling worried about offending/upsetting patients were the main barriers reported. CONCLUSION: Around 6 in 10 members of the nursing, midwifery and healthcare support workforce in Wales potentially do not feel comfortable to initiate a health behaviour conversation with patients about health and wellbeing. Feeling less comfortable to initiate a conversation was associated with staff demographics and organizational factors. IMPACT: We identified those less likely to initiate health behaviour conversations as well as personal and organizational barriers to initiation. This will help to target and tailor interventions to ensure staff are equipped and enabled to hold health behaviour conversations with patients.

Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people's accounts of navigating gender identity clinics.

BACKGROUND: Transgender, or trans, people experience a number of barriers to accessing gender-affirming healthcare and have a range of barriers and facilitators to primary care and specialist services, commonly citing discrimination and cisgenderism playing a central role in shaping accessibility. The pathway through primary care to specialist services is a particularly precarious time for trans people, and misinformation and poorly applied protocols can have a detrimental impact on wellbeing. METHOD: We recruited trans participants from an HIV Self-Testing Public Health Intervention (SELPHI) trial to interviews which explored contemporary gender-affirming service experiences, with an aim to examine the path from primary care services through to specialist gender services, in the UK. RESULTS: A narrative synthesis of vignettes and thematic analysis of in-depth qualitative interviews were conducted with twenty trans individuals. We summarise positive and negative accounts of care under three broad categories: Experiences with primary care physicians, referrals to gender identity clinics (GICs), and experiences at GICs. CONCLUSIONS: We discuss implications of this research in terms of how to improve best practice for trans people attempting to access gender-affirming healthcare in the UK. Here we highlight the importance of GP's access to knowledge around pathways and protocols and clinical practice which treats trans patients holistically.

Developing a model to predict individualised treatment for gonorrhoea: a modelling study.

OBJECTIVE: To develop a tool predicting individualised treatment for gonorrhoea, enabling treatment with previously recommended antibiotics, to reduce use of last-line treatment ceftriaxone. DESIGN: A modelling study. SETTING: England and Wales. PARTICIPANTS: Individuals accessing sentinel health services. INTERVENTION: Developing an Excel model which uses participants' demographic, behavioural and clinical characteristics to predict susceptibility to legacy antibiotics. Model parameters were calculated using data for 2015-2017 from the Gonococcal Resistance to Antimicrobials Surveillance Programme. MAIN OUTCOME MEASURES: Estimated number of doses of ceftriaxone saved, and number of people delayed effective treatment, by model use in clinical practice. Model outputs are the predicted risk of resistance to ciprofloxacin, azithromycin, penicillin and cefixime, in groups of individuals with different combinations of characteristics (gender, sexual orientation, number of recent sexual partners, age, ethnicity), and a treatment recommendation. RESULTS: Between 2015 and 2017, 8013 isolates were collected: 64% from men who have sex with men, 18% from heterosexual men and 18% from women. Across participant subgroups, stratified by all predictors, resistance prevalence was high for ciprofloxacin (range: 11%-51%) and penicillin (range: 6%-33%). Resistance prevalence for azithromycin and cefixime ranged from 0% to 13% and for ceftriaxone it was 0%. Simulating model use, 88% of individuals could be given cefixime and 10% azithromycin, saving 97% of ceftriaxone doses, with 1% of individuals delayed effective treatment. CONCLUSIONS: Using demographic and behavioural characteristics, we could not reliably identify a participant subset in which ciprofloxacin or penicillin would be effective. Cefixime resistance was almost universally low; however, substituting ceftriaxone for near-uniform treatment with cefixime risks re-emergence of resistance to cefixime and ceftriaxone. Several subgroups had low azithromycin resistance, but widespread azithromycin monotherapy risks resistance at population level. However, this dataset had limitations; further exploration of individual characteristics to predict resistance to a wider range of legacy antibiotics may still be appropriate.