A public health approach to estimating the need for long COVID services.

BACKGROUND: The term 'long COVID' describes ongoing symptoms and conditions experienced by people infected with SARS-CoV-2. This paper illustrates how a public health approach was used to influence and inform the development of post-COVID services across two Integrated Care Systems (ICSs). METHODS: A literature review was conducted between October and December 2020 to identify prevalence estimates for long COVID. The prevalence estimates were applied to locally available data on the susceptible population to estimate the number of people with long COVID. They were also used to develop a dashboard to predict fluctuations in the number of people experiencing persistent symptoms over time. RESULTS: A substantial number of people in each ICS may have experienced persistent symptoms or complications as a result of COVID-19. In Lancashire and South Cumbria, it is estimated that 33 000 people may have experienced post-COVID-19 syndrome since the beginning of the pandemic, which will include respiratory or cardiovascular complications. CONCLUSIONS: The findings have been valuable in informing early service developments, engaging with managers and clinicians, and supporting applications for funding at a local level. Continued attention to emergent evidence on this topic will be vital in refining estimates and supporting service planning in the longer term.

Changes in daily mental health service use and mortality at the commencement and lifting of COVID-19 'lockdown' policy in 10 UK sites: a regression discontinuity in time design.

OBJECTIVES: To investigate changes in daily mental health (MH) service use and mortality in response to the introduction and the lifting of the COVID-19 'lockdown' policy in Spring 2020. DESIGN: A regression discontinuity in time (RDiT) analysis of daily service-level activity. SETTING AND PARTICIPANTS: Mental healthcare data were extracted from 10 UK providers. OUTCOME MEASURES: Daily (weekly for one site) deaths from all causes, referrals and discharges, inpatient care (admissions, discharges, caseloads) and community services (face-to-face (f2f)/non-f2f contacts, caseloads): Adult, older adult and child/adolescent mental health; early intervention in psychosis; home treatment teams and liaison/Accident and Emergency (A&E). Data were extracted from 1 Jan 2019 to 31 May 2020 for all sites, supplemented to 31 July 2020 for four sites. Changes around the commencement and lifting of COVID-19 'lockdown' policy (23 March and 10 May, respectively) were estimated using a RDiT design with a difference-in-difference approach generating incidence rate ratios (IRRs), meta-analysed across sites. RESULTS: Pooled estimates for the lockdown transition showed increased daily deaths (IRR 2.31, 95% CI 1.86 to 2.87), reduced referrals (IRR 0.62, 95% CI 0.55 to 0.70) and reduced inpatient admissions (IRR 0.75, 95% CI 0.67 to 0.83) and caseloads (IRR 0.85, 95% CI 0.79 to 0.91) compared with the pre lockdown period. All community services saw shifts from f2f to non-f2f contacts, but varied in caseload changes. Lift of lockdown was associated with reduced deaths (IRR 0.42, 95% CI 0.27 to 0.66), increased referrals (IRR 1.36, 95% CI 1.15 to 1.60) and increased inpatient admissions (IRR 1.21, 95% CI 1.04 to 1.42) and caseloads (IRR 1.06, 95% CI 1.00 to 1.12) compared with the lockdown period. Site-wide activity, inpatient care and community services did not return to pre lockdown levels after lift of lockdown, while number of deaths did. Between-site heterogeneity most often indicated variation in size rather than direction of effect. CONCLUSIONS: MH service delivery underwent sizeable changes during the first national lockdown, with as-yet unknown and unevaluated consequences.

A qualitative exploration of the barriers to and facilitators of clozapine monitoring in a secure psychiatric setting.

AIMS AND METHOD: To explore the beliefs and understanding of staff and patients at a secure mental health unit regarding clozapine monitoring, and to identify barriers to and facilitators of monitoring. Qualitative semi-structured interviews and focus groups were conducted with 17 staff members and six patients. RESULTS: Six key themes were identified. The key facilitator of effective monitoring was the motivation of staff to help patients to become independent and facilitate recovery. An important barrier was a lack of clarity around the roles of different staff groups in monitoring. Staff and patients widely supported the establishment of an in-patient clozapine clinic and perceived that it would prepare patients for discharge. CLINICAL IMPLICATIONS: An in-patient clozapine clinic is a robust mechanism for clozapine monitoring in secure settings. The barriers and facilitators identified here could be applied to other secure units to guide their systems of clozapine monitoring.

Online behaviour change technique training to support healthcare staff 'Make Every Contact Count'.

BACKGROUND: National Health Service (NHS) staff support service users to change health-related behaviours such as smoking, alcohol consumption, diet and physical activity. It can be challenging to discuss behaviour changes with service users hence training is needed to equip staff with up-to-date, evidence-based behaviour change skills. In order to identify how training may help to improve health professional skills in this area, this study evaluated change in professionals' behavioural determinants following an online behaviour change skills module as part of Making Every Contact Count (MECC) training. METHODS: This evaluation comprised a within-subject design in which staff from one Northwest England NHS Trust completed a 9-item survey immediately before and after training. This prospective survey identified behavioural determinants regarding adhering to MECC recommendations to hold health conversations with service users and provided written comments about their training experiences. Individuals working within the Trust in clinical or non-clinical roles were eligible to take part and were invited to contribute to the evaluation upon uptake of their usual NHS staff online training programmes. RESULTS: Of participants completing the evaluation (n=206), 12 professional cadres accessed the module, most being female (91%), nurses/midwives (43%), working in children and family services (48%), aged 22 - 62 years. Eight behavioural determinants increased significantly following training, with effect sizes ranging from sizes ranging from 0.27 to 0.51; 'identity' did not change. Content analysis of written feedback (n=256) indicates that training enhanced staff behaviour change skills, modelled a productive and specific method of adopting a patient-led approach to behaviour change conversations, and identified that staff may require further support with embedding skills in practice. CONCLUSIONS: Behaviour change science can be translated into useful learning for NHS staff. Online training can engage staff in learning about behaviour change skills and increase their behavioural determinants to adopt these skills in practice.

Implementing National Institute for Health and Care Excellence smoke-free guidance in a secure facility: an evaluation of the prescribing costs in clozapine users.

Aims and method The increased rates of smoking in people with mental illness is well documented, and establishing smoke-free mental health environments has been emphasised over recent years. This article examines the financial costs of implementing smoke free guidance and assesses the cost associated with patients who were prescribed clozapine and who committed to stopping smoking cigarettes for the duration of the study period. RESULTS: Patients (38) who were prescribed clozapine were included in the study. A moderate reduction in dose was noted with a moderate reduction in prescribing costs. The total increase in cost for the whole group, however, was £17 624, largely due to the use of nicotine replacement therapy and an increase in the number of clozapine assay tests. Clinical implications Further studies on implementing this important policy change are needed. The positive effects must be balanced with increased financial pressure on Mental Health Trusts. Declarations of interest None.

Are health and well-being strategies in England fit for purpose? A thematic content analysis.

BACKGROUND: Since 1 April 2013, local authority (LA) health and well-being boards (HWBs) in England are required to publish a health and well-being strategy (HWS). HWSs should identify how population health needs are to be addressed. The extent to which this has been achieved is not known. We analysed HWSs to assess how LAs have interpreted statutory guidance, how evidence has been used within HWSs and the relationship of HWSs to Joint Strategic Needs Assessments (JSNAs). METHODS: Qualitative thematic content analysis of a random sample of one-third of upper tier LA HWSs in 2013-14. RESULTS: Fifty out of 152 LAs were sampled and 47 HWSs analysed. Strategies varied in timescale, length and structure. The term 'evidence' was used most commonly referring to local need, rather than evidence of effectiveness. All, except two, referred to JSNAs. CONCLUSIONS: HWSs are dominated by evidence of need and could be strengthened by greater use of evidence of effectiveness for public health interventions. Public health agencies and academics can support the development of effective HWSs by improving the accessibility of evidence and conducting research when evidence is absent. To strengthen HWSs' impact, the statutory guidance should clarify the distinction between evidence of need and evidence of effectiveness.

Future orientation and smoking cessation: secondary analysis of data from a smoking cessation trial.

AIMS: To examine the association between future orientation (how individuals consider and value outcomes in the future) and smoking cessation at 4 weeks and 6 months post quit-date in individuals enrolled in a smoking cessation study. DESIGN: Cohort analysis of randomized controlled trial data. SETTING: UK primary care. PARTICIPANTS: Adults aged ≥18 years smoking ≥15 cigarettes daily, prepared to quit in the next 2 weeks. MEASUREMENTS: Future orientation was measured prior to quitting and at 4 weeks post-quitting using the Consideration of Future Consequences Scale. Smoking cessation at 4 weeks and 6 months was confirmed biochemically. Those lost to follow-up were assumed to not be abstinent. Potential confounders adjusted for were: age, gender, educational attainment, nicotine dependence and longest previous period quit. FINDINGS: A total of 697 participants provided data at baseline; 422 provided information on future orientation at 4 weeks. There was no evidence of an association between future orientation at baseline and abstinence at 4 weeks [adjusted odds ratio (aOR) = 1.05, 95% confidence intervals (CI) 0.80-1.38] or 6 months (aOR = 0.85, 95% CI = 0.60-1.20). There was no change in future orientation from baseline to 4 weeks and no evidence that the change differed between those who were and were not quit at 4 weeks (adjusted regression coefficient = -0.04, 95% CI = -0.16 to 0.08). CONCLUSIONS: In smokers who are prepared to quit in the next 2 weeks, the extent of future orientation is unlikely to be a strong predictor of quitting over 4 weeks or 6 months and any increase in future orientation following quitting is likely to be small.

What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England.

BACKGROUND: Around 5,000 miscarriages and 300 perinatal deaths per year result from maternal smoking in the United Kingdom. In the northeast of England, 22% of women smoke at delivery compared to 14% nationally. Midwives have designated responsibilities to help pregnant women stop smoking. We aimed to assess perceived implementation difficulties regarding midwives' roles in smoking cessation in pregnancy. METHODS: A self-completed, anonymous survey was sent to all midwives in northeast England (n = 1,358) that explores the theoretical explanations for implementation difficulties of four behaviours recommended in the National Institute for Health and Clinical Excellence (NICE) guidance: (a) asking a pregnant woman about her smoking behaviour, (b) referring to the stop-smoking service, (c) giving advice about smoking behaviour, and (d) using a carbon monoxide monitor. Questions covering Michie et al.'s theoretical domain framework (TDF), describing 11 domains of hypothesised behavioural determinants (i.e., 'knowledge', 'skills', 'social/professional role/identity', 'beliefs about capabilities', 'beliefs about consequences', 'motivation and goals', 'memory', 'attention and decision processes', 'environmental context and resources', 'social influences', 'emotion', and 'self-regulation/action planning'), were used to describe perceived implementation difficulties, predict self-reported implementation behaviours, and explore relationships with demographic and professional variables. RESULTS: The overall response rate was 43% (n = 589). The number of questionnaires analysed was 364, following removal of the delivery-unit midwives, who are not directly involved in providing smoking-cessation services. Participants reported few implementation difficulties, high levels of motivation for all four behaviours and identified smoking-cessation work with their role. Midwives were less certain about the consequences of, and the environmental context and resources available for, engaging in this work relative to other TDF domains. All domains were highly correlated. A principal component analysis showed that a single factor ('propensity to act'), derived from all domains, explained 66% of variance in theoretical domain measures. The 'propensity to act' was predictive of the self-reported behaviour 'Refer all women who smoke……to NHS Stop Smoking Services' and mediated the relationship between demographic variables, such as midwives' main place of work, and behaviour. CONCLUSIONS: Our findings advance understanding of what facilitates and inhibits midwives' guideline implementation behaviours in relation to smoking cessation and will inform the development of current practice and new interventions. Using the TDF as a self-completion questionnaire is innovative, and this study supports previous research that the TDF is an appropriate tool to understand the behaviour of healthcare professionals.

Price discounts on alcohol in a city in Northern England.

AIMS: To describe the extent and nature of price discounts on alcohol in Newcastle upon Tyne, England. METHODS: An observational survey in stores licensed for off-sales in December 2010 to January 2011. RESULTS: A total of 2018 price discounts in 29 stores led to a median saving of 25% and required a median purchase of 20 standard UK alcohol units. Median price per standard unit was £0.92 (US$1.49; €1.05) before discount and £0.68 (US$1.10; €0.78) after discount. CONCLUSIONS: Restriction of price discounting should be considered as a public health policy.

The association between time perspective and alcohol consumption in university students: cross-sectional study.

BACKGROUND: Heavy alcohol consumption is associated with significant morbidity and mortality. Levels of alcohol consumption among students and young people are particularly high. Time perspective describes the varying value individuals place on outcomes in the present and future. In general, it has been found that individuals prefer to receive a gain today rather than in the future. There is evidence that time perspective is associated with addictive health behaviours, including alcoholism and cigarette smoking, but less evidence of its association with non-addictive, but hazardous, levels of alcohol consumption. The objective was to determine if there is an association between time perspective and hazardous alcohol consumption. METHODS: A cross-sectional survey using a self-completion questionnaire was administered to willing undergraduate students attending a convenience sample of lectures in two university faculties. Hazardous alcohol consumption was defined as a score of ≥8 on the Alcohol Use Disorders Identification Test (AUDIT) and time perspective was measured using the Consideration of Future Consequences Scale (CFCS). Participants were 322 undergraduate university students in two faculties at a university in Northern England, UK. RESULTS: Hazardous alcohol consumption was reported by 264 (82%) respondents. After controlling for potential confounding by socio-demographic variables, greater consideration of future consequences was associated with lower odds of reporting hazardous drinking [odds ratio = 0.28; 95% confidence interval 0.15-0.54]. CONCLUSION: Interventions aimed at increasing future orientated time perspective may be effective in decreasing hazardous alcohol consumption in students.

Primary care trusts. Triple vision.

Primary care trust chief executives need the ability to connect with a variety of organisations and groups. They need to maintain a strategic vision. They must be able to deliver on targets at the same time as delegating power and allowing local flexibility. Their behaviour and values set the tone for the organisation.