Estimating productivity levels in primary medical services across clinical commissioning groups in England and the impact of the COVID-19 pandemic: a data envelopment analysis.

OBJECTIVES: To assess the relative productivity of primary medical services in England and the impact of the COVID-19 pandemic on productivity levels. SETTING: Primary medical services for 59 million patients (98% of the population in England), in 101 clinical commissioning groups (CCGs), across two time periods: period 1, pre-pandemic, April to December 2019 and period 2, pandemic, April to December 2020. METHODS: We use data envelopment analysis (DEA) to assess relative productivity with four input measures (the number of full-time equivalent general practitioners, nurses, other direct patient contact staff and administrators), and five output measures (face-to-face appointments, remote consultations, home visits, referrals to secondary care and prescriptions). Our units of analysis were CCGs. DEA assigns an efficiency score to a CCG, taking a value between 0 and 100%, by benchmarking it against the most productive CCGs. We use Tobit regression to examine the association between productivity and other factors. RESULTS: The mean bias-corrected efficiency score of primary medical services in CCGs was 92.9% (interquartile range 92.0% to 95.7%) in period 1, falling to 90.6% (interquartile range 86.8% to 95.2%) in period 2. In period 1, CCGs with a higher proportion of registered patients aged over 65 years, higher levels of deprivation, lower levels of disease prevalence, higher nurse to GP ratios and higher GP to other direct patient contact staff ratios, achieved statistically significantly higher general practice efficiency scores (p < 0.05). In period 2, only the ratio of GP to other direct patient contact staff was associated with efficiency scores (p > 0.05). CONCLUSIONS: Our analysis indicates only modest geographic variation in productivity of primary medical services when measured at the level of clinical commissioning groups and a small reduction in productivity during the pandemic. Further work to establish relative productivity of individual GP practices is warranted once sufficient data on appointment rates by GP practice is available.

A multi-firearm, multi-orientation audio dataset of gunshots.

Early detection of firearm discharge has become increasingly critical for situational awareness in both civilian and military domains. The ability to determine the location and model of a discharged firearm is vital, as this can inform effective response plans. To this end, several gunshot audio datasets have been released that aim to facilitate gunshot detection and classification of a discharged firearm based on acoustic signatures. However, these datasets often suffer from a lack of variety in the orientations of recording devices around the source of the gunshot. Additionally, these datasets often suffer from the absence of proper time synchronization, which prevents the usage of these datasets for determining the Direction of Arrival (DoA) of the sound. In this paper, we present a multi-firearm, multi-orientation time-synchronized audio dataset collected in a semi-controlled real-world setting - providing us a degree of supervision - using several edge devices positioned in and around an outdoor firing range.

The Frequency of Infant-Feeding Presentations at English Emergency Departments During the SARS-CoV-2 Pandemic: A Nation-Wide Electronic Health Records Study.

OBJECTIVES: To examine the frequency and distribution of infant feeding-related presentations at emergency departments (EDs) before and during the SARS-CoV-2 pandemic. SETTING: Attendances at 48 major EDs in England in two 50-week periods before and during the COVID-19 pandemic: period 1, April 2, 2019 to March 10, 2020 and period 2, April 1, 2020 to March 10, 2021. METHODS: We estimated the change in frequency of ED presentations by age group and diagnosis before and after the start of the SARS-CoV-2 pandemic in England. We compared changes in the frequency of attendances of infant-feeding related presentations by infant age, sex, ethnicity, deprivation, rurality, arrival mode, arrival time, acuity, mother's age, gravidity and mental health, birth length of stay, attendance duration, and disposal (i.e., admission or discharge). RESULTS: While total ED attendances fell by 16.7% (95% CI -16.8% to -16.6%), infant attendances increased for feeding problems (+7.5% 95% CI 2.3% to 13.0%), neonatal jaundice (+12.8%, 95% CI 3.3% to 23.3%) and gastro-esophageal reflux (+9.7%, 95% CI 4.4% to 15.2%). These increases were more pronounced amongst first babies (+22.4%, 95% CI 13.1% to 32.5%), and where the stay in hospital after birth was brief (0-1 days, +20.1%, 95% CI 14.8% to 25.7%). Our analysis suggests that many of these attendances were of low acuity. CONCLUSIONS: While ED attendances reduced dramatically and systematically with the COVID-19 pandemic, presentations for infant feeding issues increased, implying growth in the unmet needs of new mothers and infants.

Equity of access to NHS-funded hip replacements in England and Wales: Trends from 2006 to 2016.

Background: Elective hip replacement is a cost-effective means of improving hip function. Previous research has suggested that the supply of hip replacements in the NHS is governed by the inverse care law. We examine whether inequities in supply improved in England and Wales between 2006 and 2016. Methods: We compare levels of need and supply of NHS funded hip replacements to adults aged 50+ years, across quintiles of deprivation in England and Wales between 2006 and 2016. We use data from routine health records and a large longitudinal study and adjust for age and sex using general additive negative-binomial regression. Findings: The number of NHS-funded hip replacements per 100,000 population rose substantially from 272.6 and 266.7 in 2002, to 539.7 and 466.3 in 2018 in England and Wales respectively. Having adjusted for age and sex, people living in the most deprived quintile were 2.36 (95% CI, 1.69 to 3.29) times more likely to need a hip replacement in 2006 than those living in quintile 3, whereas those living in the least deprived quintile were 0.45 (95% CI, 0.39 to 0.69) as likely. Despite this, people living in the most deprived quintile were 0.81 (95% CI, 0.78 to 0.83) times as likely in England and 0.93 (95% CI, 0.84 to 1.04) as likely in Wales to receive an NHS-funded hip replacement in 2006 than those living in quintile 3. We found no evidence that these substantial inequities had reduced between 2006 and 2016. Interpretation: With respect to hip-replacement surgery in England and Wales, policy ambitions to reduce healthcare inequities have not been realised. Funding: This work was supported by Health Data Research UK.

Socioeconomic differences in recruitment and sickness absence in a large NHS health organisation: a cross-sectional study.

OBJECTIVE: This study investigates the distribution of the workforce of one large National Health Service (NHS) employer in relation to socioeconomic deprivation and how sickness absence rates varied across these levels of deprivation. DESIGN: Share of the working age population that was employed at the NHS organisation mapped by area deprivation. The study used negative binomial regression models to investigate the extent to which wage level, occupational group and area deprivation were associated with sickness absence among employees. SETTING: The study used electronic staff records (2018-2019) of a large NHS organisation in the North West of England. RESULTS: In the most deprived areas, an additional person per 1000 working age population were employed at this NHS organisation compared with the most affluent areas. Employees from the most deprived quintile had 1.41 (95% CI 1.16 to 1.70) times the higher sickness rates than the employees from the least deprived quintile, when adjusting for age and sex. These differences were largely explained by differences in wage levels and occupation groups, with the lowest wage employees having 2.5 (95% CI 1.87 to 3.42) times the sickness absence rate as the highest wage group and the nursing and midwifery employees having 1.8 (95% CI 1.50 to 2.24) times the sickness absence rate as the administrative and clerical group. CONCLUSION: This large NHS organisation employed people disproportionately from deprived areas. They were considerably more likely to experience sickness absence compared with people from affluent areas. This appears to be because they were more likely to be in lower wage employment and employed in nursing and nursing assistant. Workplace health policies need to target these workers, adapting to their needs while enabling improvements in their working conditions, pay and career progression.

Relationship between emergency department and inpatient occupancy and the likelihood of an emergency admission: a retrospective hospital database study.

BACKGROUND: We investigate whether admission from a consultant-led ED is associated with ED occupancy or crowding and inpatient (bed) occupancy. METHODS: We used general additive logistic regression to explore the relationship between the probability of an ED patient being admitted, ED crowding and inpatient occupancy levels. We adjust for patient, temporal and attendance characteristics using data from 13 English NHS Hospital Trusts in 2019. We define quintiles of occupancy in ED and for four types of inpatients: emergency, overnight elective, day case and maternity. RESULTS: Compared with periods of average occupancy in ED, a patient attending during a period of very high (upper quintile) occupancy was 3.3% less likely (relative risk (RR) 0.967, 95% CI 0.958 to 0.977) to be admitted, whereas a patient arriving at a time of low ED occupancy was 3.9% more likely (RR 1.039 95% CI 1.028 to 1.050) to be admitted. When the number of overnight elective, day-case and maternity inpatients reaches the upper quintile then the probability of admission from ED rises by 1.1% (RR 1.011 95% CI 1.001 to 1.021), 3.8% (RR 1.038 95% CI 1.025 to 1.051) and 1.0% (RR 1.010 95% CI 1.001 to 1.020), respectively. Compared with periods of average emergency inpatient occupancy, a patient attending during a period of very high emergency inpatient occupancy was 1.0% less likely (RR 0.990 95% CI 0.980 to 0.999) to be admitted and a patient arriving at a time of very low emergency inpatient occupancy was 0.8% less likely (RR 0.992 95% CI 0.958 to 0.977) to be admitted. CONCLUSIONS: Admission thresholds are modestly associated with ED and inpatient occupancy when these reach extreme levels. Admission thresholds are higher when the number of emergency inpatients is particularly high. This may indicate that riskier discharge decisions are taken when beds are full. Admission thresholds are also high when pressures within the hospital are particularly low, suggesting the potential to safely reduce avoidable admissions.

Impact of the SARS-CoV-2 pandemic and associated lockdown measures on attendances at emergency departments in English hospitals: A retrospective database study.

BACKGROUND: The SARS-CoV-2 outbreak and associated lockdown measures have challenged healthcare. We examine how attendances to ED in England were impacted. METHODS: Interrupted time series regression (January 2019 to June 2020) of data from EDs in 41 English NHS Trusts was used to estimate the initial decrease in attendances and the rate of increase following an interruption from 11 March - 7 April 2020, which included the 23 March lockdown in England. FINDINGS: The SARS-CoV-2 interruption led to an initial 51.1% reduction (95% CI 46.3-55.9%) in ED attendances followed by a linear increase in attendances of 3.0% per week (95% CI 2.5-3.5%).  Significantly larger initial reductions were seen in those aged 0-19 years (69.1%), Indian (64.9%), Pakistani (71.8%), Bangladeshi (75.3%), African (63.5%) and Chinese people (74.5%), self-conveying attendees (60.3%) and those presenting with contusions or abrasions (66.9%), muscle and tendon injuries (65.6%), and those with a diagnosis that was not classifiable (72.7%).  Significantly smaller initial reductions were seen in those aged 65-74 years (42.6%), 75+ years (40.1%), those conveyed by ambulance (31.9%), and those presenting with the following conditions: central nervous system (44.9%), haematological (44.0%), cardiac (43.7%), gastrointestinal (43.4%), gynaecological (43.2%), psychiatric (40.4%), poisoning (39.7%), cerebro-vascular (39.0%), endocrinological (36.1%), other vascular (34.6%), and maxillo-facial (19.7%). No significant differences in the initial reduction of activity were seen in subgroups defined by sex, deprivation, urbanicity or acuity. INTERPRETATION: The SARS-CoV-2 outbreak and lockdown substantially reduced ED activity. The reduction varied by age groups, ethnicity, arrival mode and diagnostic group but not by sex, deprivation, urbanicity or acuity. FUNDING: No funding to declare.

Hospital admissions after vertical integration of general practices with an acute hospital: a retrospective synthetic matched controlled database study.

BACKGROUND: New healthcare models are being explored to enhance care coordination, efficiency, and outcomes. Evidence is scarce regarding the impact of vertical integration of primary and secondary care on emergency department (ED) attendances, unplanned hospital admissions, and readmissions. AIM: To examine the impact of vertical integration of an NHS provider hospital and 10 general practices on unplanned hospital care DESIGN AND SETTING: A retrospective database study using synthetic controls of an NHS hospital in Wolverhampton integrated with 10 general practices, providing primary medical services for 67 402 registered patients. METHOD: For each vertical integration GP practice, a synthetic counterpart was constructed. The difference in rate of ED attendances, unplanned hospital admissions, and unplanned hospital readmissions was compared, and pooled across vertical integration practices versus synthetic control practices pre-intervention versus post-intervention. RESULTS: Across the 10 practices, pooled rates of ED attendances did not change significantly after vertical integration. However, there were statistically significant reductions in the rates of unplanned hospital admissions (-0.11, 95% CI = -0.18 to -0.045, P = 0.0012) and unplanned hospital readmissions (-0.021, 95% CI = -0.037 to -0.0049, P = 0.012), per 100 patients per month. These effect sizes represent 888 avoided unplanned hospital admissions and 168 readmissions for a population of 67 402 patients per annum. Utilising NHS reference costs, the estimated savings from the reductions in unplanned care are ∼£1.7 million. CONCLUSION: Vertical integration was associated with a reduction in the rate of unplanned hospital admissions and readmissions in this study. Further work is required to understand the mechanisms involved in this complex intervention, to assess the generalisability of these findings, and to determine the impact on patient satisfaction, health outcomes, and GP workload.

Did government spending cuts to social care for older people lead to an increase in emergency hospital admissions? An ecological study, England 2005-2016.

OBJECTIVES: Government spending on social care in England reduced substantially in real terms following the economic crisis in 2008, meanwhile emergency admissions to hospitals have increased. We aimed to assess the extent to which reductions in social care spend on older people have led to increases in emergency hospital admissions. DESIGN: We used negative binomial regression for panel data to assess the relationship between emergency hospital admissions and government spend on social care for older people. We adjusted for population size and for levels of deprivation and health. SETTING: Hospitals and adult social care services in England between April 2005 and March 2016. PARTICIPANTS: People aged 65 years and over resident in 132 local councils. OUTCOME MEASURES: Primary outcome variable-emergency hospital admissions of adults aged 65 years and over. Secondary outcome measure-emergency hospital admissions for ambulatory care sensitive conditions (ACSCs) of adults aged 65 years and over. RESULTS: We found no significant relationship between the changes in the rate of government spend (£'000 s) on social care for older people within councils and our primary outcome variable, emergency hospital admissions (Incidence rate ratio (IRR) 1.009, 95% CI 0.965 to 1.056) or our secondary outcome measure, admissions for ACSCs (IRR 0.975, 95% CI 0.917 to 1.038). CONCLUSIONS: We found no evidence to support the view that reductions in government spend on social care since 2008 have led to increases in emergency hospital admissions in older people. Policy makers may wish to review schemes, such as the Better Care Fund, which are predicated on a relationship between social care provision and emergency hospital admissions of older people.

Changes in admission thresholds in English emergency departments.

BACKGROUND: The most common route to a hospital bed in an emergency is via an Emergency Department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED. METHODS: We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led EDs in England between April 2010 and March 2015. We used mixed-effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups: ambulance-conveyed children, walk-in children, ambulance-conveyed adults and walk-in adults. RESULTS: 23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010-March 2011 (year 1) and April 2014-March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed negligiblybetween year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics, the odds of admission over the 5-year period had reduced by 15.2% (95% CI 13.4% to 17.0%) for ambulance-conveyed children, 22.6% (95% CI 21.7% to 23.5%) for walk-in children, 20.9% (95% CI 20.4% to 21.5%) for ambulance conveyed adults and 22.9% (95% CI 22.4% to 23.5%) for walk-in adults. CONCLUSIONS: The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5.

Effect of pay-for-outcomes and encouraging new providers on national health service smoking cessation services in England: a cluster controlled study.

BACKGROUND: Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services. METHODS: Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs (representing 2,138,947 adult population) matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level. RESULTS: The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs (incident rate ratio 1∙108, p<0∙001, 95% CI 1∙059 to 1∙160). Eighty-five providers held 'any qualified provider' contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings. CONCLUSIONS: Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services.