Stakeholder views on the design of National Health Service perinatal mental health services: 360-degree survey.

AIMS AND METHOD: At the start of a new community perinatal mental health service in Scotland we sought the opinions and aspirations of professional and lay stakeholders. A student elective project supported the creation of an anonymous 360-degree online survey of a variety of staff and people with lived experience of suffering from or managing perinatal mental health problems. The survey was designed and piloted with trainees and volunteer patients. RESULTS: A rich variety of opinions was gathered from the 60 responses, which came from a reasonably representative sample. Respondents provided specific answers to key questions and wrote free-text recommendations and concerns to inform service development. CLINICAL IMPLICATIONS: There is clear demand for the new expanded service, with strong support for provision of a mother and baby unit in the North of Scotland. The digital survey method could be adapted to generate future surveys to review satisfaction with service development and generate ideas for further change.

Novel method to plan and design services. Using software to optimise the head and neck cancer patient's commute to hospital.

Travelling for hospital appointments represents a significant burden to patients. We have developed a computer programme that accurately evaluates patient commutes between their home and treatment hospital in public and private transport. This has been applied to a cohort of Head and Neck Cancer (HNC) patients to plan the locations of satellite hospitals and assess their impact on patients' commutes. Patients diagnosed with HNC were identified from our hospital's database between December 2019 and January 2022. Using Python, commuting distances from patients' postcodes to our tertiary referral hospital were calculated. These commutes incorporated routes along defined roads, traffic data, and were calculated using public and private transport. Patient commutes from their postcodes to four satellite hospitals were also calculated. We identified their closest hospital and compared that journey to the patients' journey to our tertiary centre. We included 709 patients in our analysis. Patients would have a significantly shorter journey distance and time in both public and private transport if satellite hospitals were used for appointments alongside our tertiary centre. Average travel times would reduce by 10 minutes in private and 25 minutes in public transport. Furthermore, 70% of patients required ≥2 forms of public transport to get to our hospital. This would drop to 44.1% of patients if satellite hospitals were included in our service. Our programme would allow the most accessible sites to be identified for establishing outreach clinics at appropriate satellite hospitals, therefore improving patient access to healthcare.

Time to complete contemporary dental procedures - estimates from a cross-sectional survey of the dental team.

BACKGROUND: There are few contemporary studies on the time taken to complete dental procedures, those most heavily relied on in the United Kingdom date back to 1999. OBJECTIVES: This work aimed to establish how long members of the dental team took to complete specific dental procedures, relevant to their scope of practice. METHODS: Data were collected via a purposive sample of 96 dentists, dental hygienists/therapists and dental nurses. Via an online survey, participants were asked to state the mean, minimum and maximum time they estimated that they took to complete individual dental procedures. RESULTS: The mean time taken to complete procedures common to both dentists and dental hygienists/therapists ranged from 3.7 to 4 min respectively for clinical note reading prior to seeing patients to 30.1 and 28 min to undertake root surface debridement. There were no significant differences between the time taken by dentists and dental hygienists/therapists to treat adult patients. However, in all but one procedure, dental hygienists/therapists reported taking longer (p = 0.04) to treat child patients. CONCLUSIONS: The data provided here represent an up to date assessment of the time taken to complete specific tasks by different members of the dental team. These data will be of value to service planners and commissioners interested in evolving a dental care system that employs a greater degree of skill-mix and preventively oriented care.

Projecting cancer prevalence by phase of care: a methodological approach for health service planning.

Background: In most developed countries, the number of cancer survivors is expected to increase in the coming decades because of rising incidence and survival rates and an aging population. These patients are heterogeneous in terms of health service demands: from recently diagnosed patients requiring first-course therapy to patients with extensive care needs and severe disabilities to long-term survivors who only need minimal care. Therefore, in terms of providing healthcare planners and policymakers with useful indicators for addressing policies according to health service demands, it is worth supplying updated measures of prevalence for groups of patients based on the level of care they require. The aim of this paper is to illustrate a new method for estimating short-term projections of cancer prevalence by phase of care that applies to areas covered by cancer registration. Methods: The proposed method combines linear regression models to project limited duration prevalence derived from cancer registry data and a session of the freely available software COMPREV to estimate the projected complete prevalence into three distinct clinically relevant phases of care: initial, continuing, and final. The method is illustrated and validated using data from the Veneto region in Italy for breast, colorectal, and lung cancers. Results: Prevalence is expected to increase in 2015-2026 for all considered cancer sites and sexes, with average annual variations spanning from 2.6% for women with lung cancer to 0.5% for men with colorectal cancer. The only exception is lung cancer prevalence in men, which shows an average annual decrease of 1.9%. The majority of patients are in the continuing phase of care, followed by the initial and final phases, except for lung cancer, where the final phase of care prevails over the initial one. Discussion: The paper proposes a method for estimating (short-term) future cancer healthcare needs that is based on user-friendly and freely available software and linear regression models. Validation results confirm the applicability of our method to the most frequent cancer types, provided that cancer registry data with at least 15 years of registration are available. Evidence from this method is addressed to policymakers for planning future cancer care, thus improving the cancer survivorship experience for patients and caregivers.

System interventions to support rural access to maternity care: an analysis of the rural surgical obstetrical networks program.

BACKGROUND: The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four "pillars": increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology. METHODS: We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings. FINDINGS: Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models. CONCLUSION: Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.

Understanding the current and future usage of donor human milk in hospitals: An online survey of UK neonatal units.

The use of donor human milk (DHM) where there is a shortfall of maternal milk can benefit both infant and maternal outcomes but DHM supply is not always assured. This study aimed to understand current DHM usage in UK neonatal units and potential future demand to inform service planning. An online survey was disseminated to all UK neonatal units using Smart Survey or by telephone between February and April 2022 after development alongside neonatal unit teams. Surveys were completed by 55.4% of units (108/195) from all 13 Operational Delivery Networks. Only four units reported not using DHM, and another two units only if infants are transferred on DHM feeds. There was marked diversity in DHM implementation and usage and unit protocols varied greatly. Five of six units with their own milk bank had needed to source milk from an external milk bank in the last year. Ninety units (84.9%) considered DHM was sometimes (n = 35) or always (n = 55) supportive of maternal breastfeeding, and three units (2.9%) responded that DHM was rarely supportive of breastfeeding. Usage was predicted to increase by 37 units (34.9%), and this drive was principally a result of parental preference, clinical trials and improved evidence. These findings support the assumption that UK hospital DHM demand will increase after updated recommendations from the World Health Organization (WHO) and the British Association of Perinatal Medicine. These data will assist service delivery planning, underpinned by an ongoing programme of implementation science and training development, to ensure future equity of access to DHM nationally.

Using the National Mental Health Service Planning Framework to inform integrated regional planning: a case study in Tasmania, Australia.

BACKGROUND: The aim of this study was to demonstrate the application of a needs-based mental health service planning model in Tasmania, Australia to identify indicative directions for future service development that ensure the equitable provision of mental health services across the State. METHODS: The activity and capacity of Tasmania's 2018-19 mental health services were compared to estimates of required care by: (1) generating estimates of required care using the National Mental Health Service Planning Framework (NMHSPF); (2) collating administrative mental health services data; (3) aligning administrative data to the NMHSPF; and (4) comparing aligned administrative data and NMHSPF estimates to identify priority areas for service development. Findings were contextualised using information about service location, population demographics, and upcoming service development. RESULTS: Bed-based services capacity reached 85% of the NMHSPF estimate. However, access to certain bed types was inequitable across regional areas. Access to jurisdictional clinical ambulatory team-based services was lowest in the South, while overall full-time equivalent staff capacity reached 58% of the NMHSPF estimate. Access to Primary Health Tasmania (PHT) primary care services was highest in the North West; access to Medicare services was highest in the South. Collectively, activity across primary care (PHT, headspace and Medicare) reached 43% of the NMHSPF estimate. Over half of Community Managed Mental Health Support Services were state-wide services. CONCLUSIONS: This study demonstrates the application of a needs-based planning model for mental health services. Findings revealed service priority areas across Tasmania and highlight considerations for needs-based planning.

Supporting the needs of pre- and primary school children in rural Victoria: Multidisciplinary views and experiences.

PROBLEM: Predicted effects on children from the COVID-19 pandemic include poorer mental health and increased behavioural and developmental concerns. Rural children are at higher risk due to socio-economic factors, isolation and reduced access to services. Investigation by health services into the physical, social and emotional needs of children in rural areas is critical to inform local health promotion planning, service delivery priorities and workforce capacity building. SETTING: Located in a Modified Monash Model category 5, our northern Victorian health service undertook a child-focused needs assessment in order to be strategically responsive to community issues. KEY MEASURES: The project utilised a quantitative community profiling approach and qualitative interviews with a purposive sample (n = 17) of multidisciplinary professionals. STRATEGIES FOR CHANGE: Three main themes emerged: (1) Perpetual navigation of rural access limitations highlighted professionals' exhaustion in working in environments with ongoing unmet needs. (2) Cycles of disadvantage and early intervention gaps identified flow-on negative effects, with concerning trends in poorer child outcomes. (3) Solutions through collaboration grouped ideas to improve support for children. EFFECTS OF CHANGE: Community-level enablement strategies could increase contact with allied health professionals for rural children and reduce reliance on individualised treatment approaches. LESSONS LEARNT: One collaborative action is to pilot and evaluate allied health student placement models to deliver group programs for rural children.

Referral and triage patterns of a new rural paediatric outpatient service in south-western Victoria, Australia.

INTRODUCTION: There is limited available information describing referral and triage patterns for rural paediatric outpatient clinics to guide health service planning and delivery. To address this, referrals for all new patients who attended an appointment during the initial year of a new rural paediatric outpatient service in Portland, Victoria, Australia were examined. METHODS: This was a retrospective review of referrals with initial consultations between 29 October 2018 and 28 October 2019. RESULTS: A total of 149 referrals for new patients were received, equating to a referral rate of 31.6 referrals per 1000 children for the service's Local Government Area (LGA). A total of 65.1% of new patients had not previously engaged with a paediatric service. Overall, 66.6% of referrals were triaged as having a behavioural or developmental problem. The median time from referral letter to initial appointment was 63 days, with referrals that were triaged as behavioural or developmental having an average wait time of 86 days until initial appointment. CONCLUSION: The establishment of this new rural paediatric service showed a latent need within the service's LGA, as demonstrated by higher referral rates compared to previously published studies and a majority patient population who had not previously accessed paediatric services. The greatest area of need identified by referral analysis was for behavioural and developmental problems.

If you build it who will come? Case mix data of a new rural paediatric outpatient clinic.

INTRODUCTION: There is limited current evidence describing the case mix data of rural paediatric outpatient clinics. Collection and analysis of this data is essential for health service planning, facilitating the identification of areas of need within specific communities to support contextualised delivery of paediatric health care. OBJECTIVE: To describe the case mix of patients seen during the initial 12 months of a rural paediatric service, providing evidence to inform rural health service planning. DESIGN: A retrospective cohort study. RESULTS: There were 149 initial consultations during the study period. Behavioural/developmental problems were found in 71.8% of patients and physical problems were present in 64.4% of patients. This resulted in 38.9% of patients having a combination of problem types. 42.9% of patients were referred to or already accessing allied health services, while 20% were accessing specialised paediatric support services such as the National Disability Insurance Scheme and child protection services. Investigations were ordered for 45% of patients, with medications prescribed in 43% of cases. Only 5.4% of patients were discharged after their initial appointment. There were significant differences in problems identified on the referral compared to at the initial appointment demonstrating the value of this service to a rural community. CONCLUSION: The case mix data illustrates a rural paediatric cohort with a complex and chronic burden of disease especially in terms of behavioural and developmental problems. These findings add to the literature on rural paediatric patient care and demonstrate the value of an embedded paediatric service in a medium sized rural town.

From population numbers to population needs: Incorporating epidemiological change into health service planning in Australia.

BACKGROUND: In the face of rapidly ageing populations and increasing costs of health care provision, questions continue to be raised about the long-term sustainability of publicly funded health care programmes around the world. But despite increasing evidence of dynamic changes in epidemiology, most official health service planning models continue to rely on the implicit assumption that age-specific requirements for services (and by implication age-specific needs for care) will remain constant across future years ('constant-use models'). OBJECTIVES: In this paper, we discuss the advantage of dynamic 'changing needs' planning models, compared to 'constant-use' planning models, and consider a framework that integrates population needs directly into health service planning. Using Australian survey data, we empirically illustrate the difference between static health service planning approaches to dynamic needs-driven planning models. METHODS: We use data from the Household, Income and Labour Dynamics Survey in Australia (HILDA) to explore trends in health needs from 2001 to 2020. We subsequently simulate a 'changing-needs' planning model where changes in health needs by birth-cohorts are incorporated into official government estimates from the Australian Intergenerational Reports (IGR) to understand the potential impact on future health care requirements. RESULTS: Our results show that healthy ageing trends are being observed for successive birth-cohorts with these trends greatest in older age groups, the age groups for which health care expenditures are largest. Adjusting for these changes in needs using Australian data leads to reductions in the expenditures required for future years ranging from 1.5 (2.50%) to 3 billion (5.25%) 2019 AUD. CONCLUSION: We conclude that 'constant-use' planning models based on the expected future numbers of people in different age groups applied to current levels of service use by age groups without any consideration given to changing age-specific needs for health care lead to inefficient resource planning.

The Health and Psychosocial Profiles of Adults Who Sought Mental Health and Addiction Specialty Services Through a Centralized Intake Process in Nova Scotia in 2020 and 2021.

OBJECTIVES: (1) To calculate the proportions of people who sought mental health and addiction (MHA) specialty services in Nova Scotia, overall and by sex and age. (2) To describe the health and psychosocial profiles of the MHA Intake clients. (3) To identify factors associated with acceptance for MHA services. METHODS: The data of the Nova Scotia MHA Intake clients aged 19 to 64 years old in 2020 (N = 10,178) and in 2021 (N = 12,322) were used. The proportions of unique clients in the general population were calculated based on 2021 census data. The percentages of primary presenting concerns, the presence and frequency of psychiatric symptoms in the past month, suicide risk levels, current or past provisional psychiatric diagnosis, medical problems, and psychosocial stressors were calculated. Logistic regression was conducted to identify factors associated with the acceptance of MHA services after the assessment. RESULTS: It was found that 1.48% and 2.33% of Nova Scotians aged 19 to 64 contacted the MHA Intake in 2020 and 2021. Over 66% were self-referrals, followed by physician referrals (28.34%). Mood (28.3%), anxiety (25.17%), and substance use (19.81%) were the top three presenting concerns for the contact. Many clients had a current or past provisional psychiatric diagnosis (58.7% in 2020, 61.8% in 2021). Among the clients, 74.67% and 68.29% reported at least 1 psychosocial stressor in 2020 and 2021, respectively. The clients with a current or past psychiatric diagnosis, suicide risk, and 2 or more psychosocial stressors, those who lived outside of Central Zone, and who had employee assistance program benefits/private insurance, were more likely to be qualified and accepted for MHA services than others. CONCLUSIONS: The Intake clients have complex health and psychosocial profiles. Future studies are needed to monitor the trajectories of the clients to reduce inequities in receiving MHA services and improve client outcomes.

Feasibility issues impacting optimal levels of maternity care in rural communities: implementing the Rural Birth Index in British Columbia.

INTRODUCTION: The continued attrition of maternity services across rural communities in high resource countries demands a rigorous, systematic approach to determining population level need, including a clear understanding of feasibility issues that may constrain achieving and sustaining recommended levels of services. The Rural Birth Index (RBI) proposes a robust and objective methodology to determine such need along with attention to the feasibility of implementation. BACKGROUND: Predictions of appropriate levels of maternity care in rural communities require consideration of the feasibility of implementation. Although previous work has focused on essential considerations that impact feasibility, there is little research documenting the barriers to implementation from the perspective of rural care providers and administrators. METHODS: We conducted in-depth, qualitative research interviews with rural community health care administrators and providers (n = 14) to understand the challenges of offering maternity care in 10 rural communities across British Columbia (BC). RESULTS: Participants articulated three thematic challenges to providing maternity services in their communities: maintaining clinical skills and financial stability in the context of low procedural volume, recruitment and retention of care providers and challenges with patient transport. CONCLUSIONS: Current models of compensation for maternity care are inadequate and inflexible and underscore many of the challenges to implementing a level of care that is based on population need. Re-thinking provision of care as a social obligation to actualize our system commitment to equity instead of working to achieve economies of scale is the first step to use equitable care. Addressing remuneration will provide the groundwork for solving other barriers to sustainable care.

Applying systems leadership and participatory action research in developing a water contamination management tool.

OBJECTIVE: This research used systems leadership to explore stakeholder engagement regarding requirements, incentives and barriers to adopting a faecal source tracking method to identify contamination sources in surface waters. SETTING: The research comprised two branches, one quantitative, conducted in a food and water laboratory; the other qualitative, conducted within stakeholder organisations and meeting premises. PARTICIPANTS: Ten stakeholder representatives participated in semi-structured interviews and ten in a focus group. Seven individuals participated in both activities while three who were interviewed were replaced by alternate representatives for the focus group. DESIGN: A multimethod participatory action research project was completed, with a quantitative trial of a microbial source tracking method conducted concurrently with two iterations of qualitative research into the needs of the stakeholder system through semi-structured interviews and a focus group. RESULTS: Thematic analysis of stakeholder interviews yielded key incentive and barrier themes, while the laboratory trial created a comparison library and tested the efficacy of the laboratory method. The focus group further explored key themes and identified requirements for collaborative effort across the system, and the need to address misinterpretation of statistical associations. CONCLUSION: Systems leadership was effective in exploring stakeholder interest in the proposed faecal source tracking method. Two iterations of qualitative research helped to identify the needs of individual stakeholders, and then develop collective strategies for addressing the critical incentives and barriers.

Complex, Co-occurring Needs Patterns and Evidence-Based Service Planning for Families Involved in Foster Care: A Map for Research and Practice.

This study described the complexity of service need co-occurrence among foster care-involved families and identified prevalent patterns of needs to inform future evidence-based service planning research. We utilized state administrative child maltreatment records, and restricted data to cases where the child entered foster care in 2019 and the caseworker indicated the presence of at least one need from the Family Assessment of Needs and Strengths (FANS; n = 1631). We extracted all unique combinations of needs (i.e., needs profiles), and we used association rule mining to identify patterns within these profiles. A total of 780 unique needs profiles emerged among the 1631 cases, which we condensed into 78 patterns. Although the variability and complexity of needs profiles makes evidence-based service planning difficult, the present analysis mapped prevalent needs patterns to guide future research intended to assist caseworkers in this task. Identification of maltreatment determinants among families involved in foster care, and future research into the needs within different needs patterns that might undermine treatment effectiveness, may result in a better balance between parsimonious service plans and a full consideration of co-occurring service needs.

Using novel methodology to estimate the prevalence of mental disorders in British Columbia, Canada.

PURPOSE: A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work. METHODS: We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature. RESULTS: Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups. CONCLUSION: We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

Regional evolution of psychosocial services in Australia before and after the implementation of the National Disability Insurance Scheme.

OBJECTIVES: This paper compares the evolution of the psychosocial sector in two Australian regions pre and post introduction of the National Disability Insurance Scheme - a major reform to the financing, planning and provision of disability services in Australia, intended to create greater competition and efficiency in the market, and more choice for service users. METHODS: We used a standardised service classification instrument based on a health ecosystems approach to assess service availability and diversity of psychosocial services provided by non-government organisations in two Primary Health Network regions. RESULTS: We identified very different evolutionary pathways in the two regions. Service availability increased in Western Sydney but decreased in the Australian Capital Territory. The diversity of services available did not increase in either Primary Health Network 4 years after the reform. Many services were experiencing ongoing funding uncertainty. CONCLUSION: Assumptions of increased efficiency through organisational scaling up, and a greater diversity in range of service availability were not borne out. IMPLICATIONS: This study shows the urgent need for evaluation of the effects of the NDIS on the provision of psychosocial care in Australia. Four years after the implementation of the NDIS at vast expense key objectives not been met for consumers or for the system as a whole, and an environment of uncertainty has been created for providers. It demonstrates the importance of standardised service mapping to monitor the effects of major reforms on mental health care as well as the need for a focus at the local level.

Optimal Planning of Health Services through Genetic Algorithm and Discrete Event Simulation: A Proposed Model and Its Application to Stroke Rehabilitation Care.

Background. Increasing demand for provision of care to stroke survivors creates challenges for health care planners. A key concern is the optimal alignment of health care resources between provision of acute care, rehabilitation, and among different segments of rehabilitation, including inpatient rehabilitation, early supported discharge (ESD), and outpatient rehabilitation (OPR). We propose a novel application of discrete event simulation (DES) combined with a genetic algorithm (GA) to identify the optimal configuration of rehabilitation that maximizes patient benefits subject to finite health care resources. Design. Our stroke rehabilitation optimal model (sROM) combines DES and GA to identify an optimal solution that minimizes wait time for each segment of rehabilitation by changing care capacity across different segments. sROM is initiated by generating parameters for DES. GA is used to evaluate wait time from DES. If wait time meets specified stopping criteria, the search process stops at a point at which optimal capacity is reached. If not, capacity estimates are updated, and an additional iteration of the DES is run. To parameterize the model, we standardized real-world data from medical records by fitting them into probability distributions. A meta-analysis was conducted to determine the likelihood of stroke survivors flowing across rehabilitation segments. Results. We predict that rehabilitation planners in Alberta, Canada, have the potential to improve services by increasing capacity from 75 to 113 patients per day for ESD and from 101 to 143 patients per day for OPR. Compared with the status quo, optimal capacity would provide ESD to 138 (s = 29.5) more survivors and OPR to 262 (s = 45.5) more annually while having an estimated net annual cost savings of $25.45 (s = 15.02) million. Conclusions. The combination of DES and GA can be used to estimate optimal service capacity. Highlights: We created a hybrid model combining a genetic algorithm and discrete event simulation to search for the optimal configuration of health care service capacity that maximizes patient outcomes subject to finite health system resources.We applied a probability distribution fitting process to standardize real-world data to probability distributions. The process consists of choosing the distribution type and estimating the parameters of that distribution that best reflects the data. Standardizing real-word data to a best-fitted distribution can increase model generalizability.In an illustrative study of stroke rehabilitation care, resource allocation to stroke rehabilitation services under an optimal configuration allows provision of care to more stroke survivors who need services while reducing wait time.Resources needed to expand rehabilitation services could be reallocated from the savings due to reduced wait time in acute care units. In general, the predicted optimal configuration of stroke rehabilitation services is associated with a net cost savings to the health care system.

The development and application of a chairside oral health risk and need stratification tool in general dental services.

OBJECTIVE: To describe the development and application of the Assessment of Clinical Oral Risks and Needs (ACORN) stratification tool based on a traffic light system in National Health Service (NHS) general dental services (GDS) Wales, UK. MATERIALS AND METHODS: This was a secondary analysis of routinely-collected dental care data. All courses of treatment provided in dental practices participating in NHS GDS Reform Programme between July 2018 and September 2019, in which an ACORN assessment and age were recorded were included in the analysis. RESULTS: A total of 236,490 subjects contributed 339,933 courses of treatment during the study period. 'Amber' and 'red' ACORN outcomes were associated with more courses of treatment per annum than 'green' outcomes. Outcomes indicating an increased risk of decay or other dental problems were associated with a greater likelihood of several operative treatment items. Patients at greater risk of poor periodontal health were more likely to receive extractions and dentures than low-risk patients. Patients were most likely to either remain in the same ACORN outcome categories or move to a healthier state between assessments. CONCLUSION: More research is required to understand the utility of the ACORN tool in risk communication and behaviour change.

Responding to the 'thin' markets of rural and remote disability services. Quantitative and spatial analysis is part of the picture.

Policymakers, funding bodies and service provider agencies require objective indicators to ensure quality, equity and access. We sought to depict the availability of rural and remote allied health and disability services in Queensland using one such indicator (spatial analysis) to explore concepts related to 'thin' markets, including market sufficiency and market diversity. Our findings suggested, counter-intuitively, that more remote settings had greater disability service sufficiency and diversity than larger regional centres. While on careful interpretation this face-value observation can be rationalised, it can also be used to influence decision making to the detriment of remote area consumers and communities. Most importantly, it does not adequately incorporate consumer, community and service provider realities in remote areas. This led us to consider additional factors that should routinely be acknowledged to broaden planning for disability services in rural and remote settings. We suggest a number of additional considerations that should also inform policy, funding and service planning decisions. The challenge facing all stakeholders is to develop new indicators that are meaningfully reflective of the realities of rural and remote consumers, families, communities and service providers, as well as market realities.