Effectiveness and cost-effectiveness of a universal parenting skills programme in deprived communities: multicentre randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness and cost utility of a universally provided early years parenting programme. DESIGN: Multicentre randomised controlled trial with cost-effectiveness analysis. SETTING: Early years centres in four deprived areas of South Wales. PARTICIPANTS: Families with children aged between 2 and 4 years. 286 families were recruited and randomly allocated to the intervention or waiting list control. INTERVENTION: The Family Links Nurturing Programme (FLNP), a 10-week course with weekly 2 h facilitated group sessions. MAIN OUTCOME MEASURES: Negative and supportive parenting, child and parental well-being and costs assessed before the intervention, following the course (3 months) and at 9 months using standardised measures. RESULTS: There were no significant differences in primary or secondary outcomes between trial arms at 3 or 9 months. With '+' indicating improvement, difference in change in negative parenting score at 9 months was +0.90 (95%CI -1.90 to 3.69); in supportive parenting, +0.17 (95%CI -0.61 to 0.94); and 12 of the 17 secondary outcomes showed a non-significant positive effect in the FLNP arm. Based on changes in parental well-being (SF-12), the cost per quality-adjusted life year (QALY) gained was estimated to be £34 913 (range 21 485-46 578) over 5 years and £18 954 (range 11 664-25 287) over 10 years. Probability of cost per QALY gained below £30 000 was 47% at 5 years and 57% at 10 years. Attendance was low: 34% of intervention families attended no sessions (n=48); only 47% completed the course (n=68). Also, 19% of control families attended a parenting programme before 9-month follow-up. CONCLUSIONS: Our trial has not found evidence of clinical or cost utility for the FLNP in a universal setting. However, low levels of exposure and contamination mean that uncertainty remains. TRIAL REGISTRATION: The trial is registered with Current Controlled Trials ISRCTN13919732.

Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs.

AIM: To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage. METHODS: Two focus groups were held at the outset of an evaluation of Treat and Refer (T&R) protocols: one with staff based at an ambulance station who were to implement the new service (intervention station), and the other with staff from a neighbouring station who would be continuing their normal practice during the study (control station). A third session was held with staff from the intervention station following training and 3 months' experience of protocol usage. RESULTS: Before the introduction of the T&R protocols, crews reported experience, intuition, training, time of call during shift, patient preference, and home situation as influencing their decisions concerning conveyance. Crews were positive about changing practice but foresaw difficulties with advising patients who wanted to go to hospital, and with referral to other agencies. Following experience of T&R protocol use, crews felt they had needed more training than had been provided. Some felt their practice and job satisfaction had improved. Problems with referral and with persuading some patients that they did not need to go to hospital were discussed. There was consensus that the initiative should be introduced across the service. CONCLUSIONS: With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.

On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature.

With rising demand and recognition of the variety of cases attended by emergency ambulance crews, services have been considering alternative ways of providing non-urgent care. This paper describes and appraises the research literature concerning on-scene alternatives to conveyance to an emergency department, focusing on the: (1) profile and outcomes of patients attended but not conveyed by emergency crews; (2) triage ability of crews; (3) effectiveness and safety of protocols that allow crews to convey patients to alternative receiving units or to self care. The literature search was conducted through standard medical databases, supplemented with manual searches. Very few "live" studies were identified, and fewer still that included a control group. Findings indicated a complex area, with the introduction of protocols allowing crews to leave patients at scene carrying clinical risk. Robust research evidence concerning alternatives to current emergency care models is needed urgently to inform service and practice development.

The costs and benefits of helicopter emergency ambulance services in England and Wales.

BACKGROUND: Following the introduction of Helicopter Emergency Ambulance Services (HEAS) in the United Kingdom in the last ten years this paper examines the costs and benefits of three contrasting services in Cornwall, London and Sussex. METHODS: Pre-hospital processes of care were compared between helicopter attended patients and land ambulance patients in all three studies, and health outcomes were compared between helicopter and land ambulance patients in the Cornwall and London studies. A review of the literature on the benefits of HEAS has also been undertaken. RESULTS: There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved. In London there was some evidence of worse residual disability in helicopter attended survivors, but in Cornwall residual disability was better in helicopter attended patients. There was no improvement in general health status or aspects of daily living in the helicopter attended patients. The overall total operational costs for these services were [symbol: see text] 55 000 p.a. in Sussex, [symbol: see text] 600 000 in Cornwall and [symbol: see text] 1.2 million in London. CONCLUSION: The analysis suggests that Helicopter Emergency Ambulance Services are costly, the health benefits are small, and there are limited circumstances in which the pre-hospital performance of an ambulance service in England and Wales can be improved.

Effects of London helicopter emergency medical service on survival after trauma.

OBJECTIVE: To assess the effect of the London helicopter emergency medical service on survival after trauma. DESIGN: Prospective comparison of outcomes in cohorts of seriously injured patients attended by the helicopter and attended by London ambulance service land ambulances crewed by paramedics. SETTING: Greater London. SUBJECTS: 337 patients attended by helicopter and 466 patients attended by ambulance who sustained traumatic injuries and died, stayed in hospital three or more nights, or had other evidence of severe injury and who were taken to any one of 20 primary receiving hospitals. MAIN OUTCOME MEASURE: Survival at six months after the incident. RESULTS: After differences in the nature and severity of the injuries in the two cohorts were accounted for the estimated survival rates were the same (relative risk of death with helicopter = 1.0; 95% confidence interval 0.7 to 1.4). An analysis with trauma and injury severity scores (TRISS) found 16% more deaths than predicted in the helicopter cohort but only 2% more in the ambulance cohort. There was no evidence of a difference in survival for patients with head injury but a little evidence that patients with major trauma (injury severity score > or = 16) were more likely to survive if attended by the helicopter. An estimated 13 (-5 to 39) extra patients with major trauma could survive each year if attended by the helicopter. CONCLUSION: Any benefit in survival is restricted to patients with very severe injuries and amounts to an estimated one additional survivor of major trauma each month. Over all the helicopter caseload, however, there is no evidence that it improves the chance of survival in trauma.