Recent developments that caught the eye

New scheme will help GPs tackle long-term conditions
 
NHS England is to launch a new pilot scheme that aims to help GPs assess the care and support needs of people with long-term conditions. 
 
A new assessment tool, known as “patient activation” has been developed to measure the knowledge, skills and confidence these patients have to manage their own health, and to highlight where they need extra support. 
 
The pilot, which will cover 150,000 people, is being launched in partnership with The King’s Fund, The Health Foundation, five clinical commissioning groups and The Renal Registry. 

The launch follows the publication of a recent report from The King’s Fund (www.kingsfund.org.uk/publications/ supporting-people-manage-their-health), which introduces the concept of patient activation and its potential for application in England. 

Research has shown that people with long-term conditions with higher activation levels have better health outcomes, while those with lower activation levels incur higher costs. 
 
Sheffield GP Dr Ollie Hart commented: “Patient activation is about a paradigm shift in how we as patients and clinicians interact to get the best possible outcomes. Working like this means I can better understand where patients with long-term conditions are coming from and match my interventions to their needs.” 

http://www.england.nhs. uk/2014/05/21/ltc-pilot/ 

New tool set to improve dementia care
 
A new web-based tool developed by the Royal College of General Practitioners has been heralded as a valuable innovation towards supporting GPs and other primary care staff in delivering dementia care. 
 
Known as the Dementia Roadmap, the resource provides a framework that areas can use to provide local information about dementia thus assisting primary care staff to more effectively support people with dementia and their carers. 
 
The current version has been populated with information relevant to three pilot sites in the South West. The platform can however be replicated across all localities and also contains national information which has been assessed by a steering group. 
 
The Roadmap can be used on a desk top computer, tablet or iPhone – allowing a GP to use it on a home visit – and has links to Twitter and email. It will be available to all healthcare professionals, as well as the general public. 
 
Dr Maureen Baker, Chair of the RCGP said: “Dementia is a clinical priority for the College and this Roadmap will be a huge step forward in helping GPs and healthcare professionals do their best for patients. 
 
http://www.dementiaroadmap.info/
Survey suggests sub-optimal HMB management
 
Data from a survey of 250 GPs have highlighted a low awareness and implementation of current NICE guidelines on heavy menstrual bleeding (HMB). 

Results from the survey, conducted by Opinion Health, show that as many as seven in 10 GPs are either unaware that the guidelines exist, or are unfamiliar with the details. 

HMB affects one in five women of reproductive age. For women who are suitable for either hormonal or non-hormonal interventions, the recommended first-line treatment for HMB is the levonorgestrel-releasing intrauterine system (LNG-IUS 20 mcg/ day). However, the survey found that only 3% of GPs routinely prescribe the LNG- IUS as a first-line treatment. The most  
frequently-prescribed first-line treatments were tranexamic acid (60%) and non- steroidal anti-inflammatory drugs (17%). 
 
The survey also revealed that a significant minority of GPs (19%) believe that the LNG-IUS is unsuitable for younger or childless women, yet research confirms that the IUS may be appropriate for all women of reproductive age.
NHS warns against pre- heated birthing pools 
 
Public Health England (PHE) and NHS England have temporarily issued a Patient Safety Alert advising against the home use of birthing pools with built-in heaters and recirculation pumps, which can potentially be filled up to two weeks in advance of the birth. 
 
The precautionary advice follows a single case of Legionnaires’ disease identified in a baby born in this specific type of birthing pool at home. 
 
Samples taken from the heated birthing pool used have confirmed the presence of legionella bacteria. 
 
This is the first reported case of Legionnaires’ disease linked to a birthing pool in England, although there have been two cases reported internationally some years ago. 
 
The alert recommends that heated birthing pools, filled in advance of labour and where the temperature is maintained by use of a heater and pump, are not used for labour or birth. In the meantime, a full risk assessment into their use is being carried out. 
 
The majority of birthing pools – those filled with hot water at the time of labour – are excluded from this alert, provided that any pumps are used solely for pool emptying. 
 
Legionella is a commonly occurring bacterium and can be found in around 10% to 20% of domestic hot water systems. However, Legionnaires’ disease is rare – and extremely so in childhood, with only one case in children aged 0-9 years reported in England between 1990 to 2011. People become infected with the bacteria through inhalation of contaminated water droplets.
Child ’flu vaccination pilots show promising results
 
Initial results of the uptake and impact of the child’ flu vaccine pilot programme launched last year by Public Health England (PHE) are encouraging, according to recent data. 
 
In 2012 the Joint Committee on Vaccination and Immunisation advised extending the national ’flu immunisation programme to all children from the age of two to less than 17 years. As a first step in the extension of the programme, last year all children aged two and three years were offered ’flu vaccination, while children aged between four and 11 years were vaccinated in seven pilot areas in England in 2013 to 2014. 
 
A total of 104,792 primary age children received at least one dose of the vaccine, representing an overall uptake of 52.5% in the target group. 
 
The cumulative influenza positivity rate in primary care in pilot areas was 8.5% compared to 16.2% in non- pilot areas. 
 
Despite the low flu activity in 2013 to 2014, early results, obtained from a range of surveillance indicators including GP consultations, swab positivity percentage of respiratory emergency department attendances, suggest a positive impact.  
  • From September 2014 the schedule for HPV vaccination, routinely offered to girls aged 12 to 13, will change from three to two doses. 
The changes have been prompted by research showing that antibody response to two doses in adolescent girls is as good as a full course in the age group targeted. Girls who have not had their first dose of HPV vaccine by the time they are 15 years old should be offered the three dose schedule, as the antibody response in older girls is not as good.
BMI ‘a flawed tool in children’
The use of body mass index (BMI) to diagnose obesity in children could lead to a significant number of cases to be missed, according to findings from a meta-analysis carried out at the Mayo Clinic,

The researchers found that while BMI has high specificity in identifying paediatric obesity, it has only a moderate sensitivity, so the measurement can miss children who should be considered obese. 

The Mayo researchers used 37 eligible studies that involving a total of 53,521 patients aged 4-18 years. The analysis showed that around 25% of children have excess body fat despite a normal BMI. 

Dr Asma Javed, the study’s lead author said: “Our research raises the concern that we very well may be missing a large group of children who potentially could be at risk for these diseases as they get older. We hope our results shine a light on this issue for physicians, parents, public health officials and policymakers.”
Survey reveals flaws in mental health services 
Insights 2-4 - Survey reveals flaws in mental health services
A survey of general practitioners in Scotland has highlighted significant shortfalls in GP training in mental health and resources for affected patients. 

Previous research has shown that around 75% of people would go first to their GP if they were concerned about their mental health. This latest survey, carried out by the Scottish Association for Mental Health, reveals that a large majority of the 465 respondents call for better resources to manage patients’ needs.  

Specifically, the survey found:   
  • 85 per cent of the doctors believed there was not enough local support for patients tackling mental health- related issues  
  • 49.9% said they last undertook accredited training on any aspect of mental health more than a year ago  
  • 11.4% said they had never undertaken accredited training on any aspect of mental health  
  • 87.3% wanted information guides on local services for referral, including social prescribing opportunities  
  • 81.6% wanted resources to help people self-manage their conditions.
The figures come after the Royal College of General Practitioners Scotland revealed that nearly a third of all GP appointments relate to mental health issues – prompting a call to extend training for doctors with a greater emphasis on mental health. “We see large numbers of patients for whom mental health problems form part of a complex health scenario,” RCGP Scotland Chair Elect, Dr Miles Mack commented. “It is vital that general practice is resourced adequately to ensure that all patients receive the services they need.”  

http://www.samh.org.uk/mental- health-information/know-where-to-go/ read-our-reports.aspx  
New evidence triggers cautious advice to soak up sun
Following new figures showing vitamin D deficiency in 23% of the adult population, the National Osteoporosis Society is emphasising the benefits of the seasonal sunshine. 

Recent guidance from NICE’s Centre for Public Health warns that one in five adults is vitamin D deficient. This is supported by new data from the National Diet and Nutrition Survey (NDNS) highlighting evidence of an increased risk of vitamin D deficiency in both adults and children.  

Claire Severgnini, Chief Executive, for the Society said: “The Sunlight Campaign is all about raising awareness of vitamin D and its importance for bone health. We want to give clear advice about how to achieve this natural health boost safely so that people can be confident about going outdoors and getting the sun exposure they need without burning and damaging their skin.”  

The Society advises that baring arms and legs to the sun, without sunscreen, for just 10 minutes, once or twice a day between 11am and 3pm is enough for most people to top up vitamin D levels to last through the winter. It also emphasises the importance of avoiding sunburn.  

For people unable to get enough sun, as well as infants and young children aged six months to five years, pregnant and breastfeeding women and people over 65 years, Public Health England recommends a daily vitamin D supplement to prevent deficiency. 
Findings suggest need for pertussis booster
A new study suggests that protection afforded by the childhood whooping cough vaccine may diminish over time, leaving vaccinated older children vulnerable to infection from the pertussis bacterium.

The study, carried out by researchers from the University of Oxford, the Respiratory and Vaccine Preventable Bacteria Reference Unit in London and Public Health England, involved 300 children who had visited their GP with a persistent cough. Researchers found that 20% of these young patients had evidence of a recent pertussis infection. Of particular concern was the fact that the majority of these children had already been fully vaccinated.  

The findings, published in the British Medical Journal, have led to calls for teenagers to be given a booster of the pertussis vaccine. UK children are vaccinated against the disease at two, three and four months of age, with a further “booster” vaccine given before they start school.  

There were over 4,500 reported cases of pertussis in England and Wales in 2013. If, as the study suggests, the vaccine does wear off in time, the infection could be passed on from teens to young babies. Babies who are too young to start their vaccinations are at greatest risk.  

The study authors recommend that the Joint Committee on Vaccination and Immunisation should conduct further investigations into whether a booster shot during the teenage years would be cost-effective.
Allergy admissions up
Admissions for allergies in NHS hospitals in England have risen by almost 8% within one year, according to new figures from the Health and Social Care Information Centre (HSCIC). 

In the 12 months to February 2014, there were 20,320 admissions for allergies, compared with 18,860 for the previous 12 months – an increase of 7.7%. Of these, 68% were emergencies, a rise of just over 6% on the same period last year. The increase was particularly sharp in the case of admission for allergic rhinitis, which rose by over 12%.  

http://www.hscic.gov.uk/pubs/ hesapr13feb14 
Guidelines Round-up 
  • Nice updates AF advice
Updated guidance from NICE has highlighted the need to ensure patients with atrial fibrillation (AF) are offered appropriate treatment to minimise stroke risk. 

AF affects around 800,000 people in the UK – including around one in 10 people over 65 – but it is thought that around 250,000 others may be undiagnosed. It is also more common in people with other heart conditions such as hypertension or atherosclerosis.  

Since 2012 a number of novel oral anticoagulants, which offer advantages over warfarin, have been approved by NICE, but there is evidence that these drugs are not being as widely prescribed as they could, the guidance states.  

Aspects covered by the new guidance include:   
  • Outlining how each patient should have a clear management plan which takes into account their personal preferences and the clinician’s view  
  • Details of previous positive appraisals by NICE of the newer anticoagulants: apixaban, dabigatran and rivaroxaban, positioning them clearly to enable the GP to support patients in their choice of preventive medication
  • The role and best use of various therapies in the management of AF, including drug therapy, cardioversion and ablation (radiofrequency pulses to destroy the area of the heart causing the arrhythmia)  
  • Advice on referral to specialist AF services, where symptoms have failed to respond to treatment.
The guideline also recommends the use of a new tool – the CHA2DS2-VASc (www. chadsvasc.org/) – to assess the risk of stroke in patients with AF and to inform treatment decisions. 

http://guidance.nice.org.uk/
  •  New guidance highlights weight management programmes
NICE has published new guidance on management of obese and overweight patients and referral to lifestyle weight management programmes focusing on diet, activity and behaviour change. 

The number of people who are overweight or obese in England is rising. More than a quarter of adults are now classified as obese and a further 42% of men and a third of women are overweight. 

Carol Weir, head of service for nutrition and dietetics at Leeds Community Healthcare NHS Trust and NICE guidance developer, said: “We need to focus on more than just diet and being more active. Using tools such as weight monitoring and setting realistic personal goals are really important.”  
  • The new guidance recommends that health professionals should:  
  • Be aware of the effort needed to lose weight, prevent weight regain or avoid any further weight gain  
  • Recognise the stigma adults who are overweight or obese may experience, and ensure the tone and content of all communications is respectful and non- judgemental  
  • Discuss the importance and benefits of making gradual, long-term changes to dietary habits and physical activity levels  
  • Explain the more weight lost, the greater the health benefits Refer overweight and obese adults to a lifestyle weight management programme, explaining what the programme does and does not involve, agreeing realistic goals and emphasising that no programme is a “quick fix” that can guarantee long-term success. 
www.nice.org.uk/guidance/index. jsp?action=byID&o=14530
  • Interim guidelines clarify rights of mental health patients
As part of a “major step” towards establishing “parity of esteem” between mental and physical health services in the NHS, NHS England has published interim guidance for GPs and commissioners in a bid to improve the support of patients in choosing their mental health care. 
Since April this year, patients with mental health conditions have had the same rights as physical health patients to choose where they have their first outpatient appointment. With the help of their GP, patients can now choose to be referred to any appropriate clinical provider in the country with whom the clinical commissioning group has a contract. 
  • Issue covered by the guidance include:  
  • Determining what is “clinically appropriate” for each eligible patient  
  • Using Choose and Book to make referrals to mental health services  
  • Information on Clinical Assessment Services  
  • How to respond to any significant changes in where patients are referred to when patients make their choices  
  • Clarity on pricing and paying for mental health services. 
Meanwhile, work is underway to improve information on mental health conditions and treatments for both patients and referrers and to ensure money follows the patients to incentivise providers. There are exemptions to the new right to choice, such as patients who need high secure psychiatric services or who are detained under the Mental Health Act, which are also set out in the guidance. 

http://www.england.nhs.uk/wp- content/uploads/2014/05/guid-choice- prov-health.pdf 
  • NICE supports VTE prevention device
NICE has issued new medical technology guidance supporting the use of geko, an innovative device for use in patients who have a high risk of venous thromboembolism (VTE), where standard antithrombotic treatments are unsuitable or contraindicated. 
 
The geko device, manufactured by British firm FirstKind, is similar in size and appearance to a small wristwatch and is fixed to the back of the knee joint via its adhesive surface. The disposable, batterypowered device creates electrical impulses to stimulate a nerve in the leg, causing muscles to contract, thereby increasing the blood flow in the veins – essentially mimicking the action of walking. The list price stated in the sponsor’s submission is £22 (excluding VAT) per pair of geko devices. https:// www.nice.org.uk/guidance/MTG19