Gloucestershire Evidence & Research Repository

Background: Social eating is a key aspect of recovery for many individuals with an Eating Disorder (ED). To develop effective interventions to support recovery of social eating we need to understand the challenges that people with ED face when eating in public spaces. This study was conducted in the context of the development of a virtual reality graded-exposure café intervention for people with ED. The current analysis explores stakeholder perspectives on the challenges that people with ED face in café environments. Methods: People with lived experience of ED (n = 15), parents/carers (n = 4) and clinicians (n = 6) took part in semi-structured focus groups and 1:1 interviews. Transcripts were analysed thematically. Results: We identified six major themes: (1) Facing the unexpected and unknown; (2) Cafés elicit difficult emotions; (3) Challenges are highly individual; (4) Challenges relating to the physical café environment; (5) Challenges of social interactions in cafés; (6) Challenges of the process of choosing and consuming food and drink. Conclusions: This study highlights the challenges cafés present for people with ED, many of which also apply to other social eating scenarios. These findings will enable more targeted support and development of novel interventions to help people with ED return to social eating. Keywords: Adolescents; Eating disorders; Lived experience; Qualitative research; Social eating; Thematic analysis; Young adults.

In Gloucestershire we are rightly proud of our strong track record in collaborative working across organisations in the wider health, care and wellbeing system. We are committed to the delivery of Integrated Neighbourhood Teams building on integrated care. Across our partnerships we strive to continuously improve the care and outcomes for our people. However we are not without our challenges. While life expectancy continues to improve for the most affluent 10%, it has either stalled or fallen for the most deprived 10%. An ageing population means there’s a growing demand and pressure on the system to remain sustainable. The Working as One transformation Programme endeavours “to deliver quality, integrated care for the people of Gloucestershire to support the best possible physical and mental health outcomes, enabling them to lead the most happy and healthy lifestyles”. One improvement cycle of the Prevention workstream of Working as One is the development of Integrated Proactive Neighbourhoods; Integrated Neighbourhood Teams focussed on proactive frailty. We know there are over 73,000 people in Gloucestershire over the age of 65 coded as frail within our GP clinical systems. If and when people in this age group attend our acute hospital emergency department, they are more likely to spend longer there than those aged under 65, and more likely than the younger age group for that attendance to lead to an admission. We are keen to prevent attendances where reasonably avoidable and where people can be proactively supported to remain in their own homes and communities. We know a patchwork of interventions has developed for different cohorts of people living with frailty. This programme enables us; a system comprising teams of teams around specific populations; to collectively work better together to improve the health and care outcomes for our populations. It is an opportunity to systematise adoption of the most impactful evidence based interventions for people across our county by cohort and individual need and positively impact the wider system. We acknowledge that, whilst transformative in many respects, this is also an evolutionary change that builds on examples of already successful integrated working practices. We’re phasing our approach across fifteen neighbourhoods in Gloucestershire to collectively run improvement and change cycles. Importantly whilst system and senior strategic colleagues can provide the structure, conditions for change and permissions for this new way of working, it is the local health and care professionals, our vibrant voluntary and community sector and people in communities who hold the key to delivering locally appropriate adaptations of the model to meet local people’s needs in a meaningful and sustainable way. Our work links most to pillars 1,2,3 and 6 of integrated care. Our key next step is convening a series of workshops to enable local teams the time and space to co-develop the integrated working in their neighbourhoods. With the support of our systemwide Improvement Community and strategic leaders, local teams will be enabled and empowered to work with people to continuously develop and iterate integrated care for, and with the people we serve.

Background Complications can be devastating for patients, but the ‘second victim’ phenomenon is increasingly being acknowledged, whereby the surgeons involved in the complication are adversely affected by such complications. For trainees, who are early into their surgical careers and are on a learning curve, such events can be formative or pivotal in their careers. Additionally, as temporary rotating members of the departments they work in, there can often be educational, interpersonal or workplace demands that amplify such effects, and a lack of professional ties that allow them to comfortably discuss complications with temporary or new work colleagues. Methods An online questionnaire was designed and distributed to UK Trauma and Orthopaedic trainees. Sixty-five trainees responded from across ten deaneries. Results There were significant negative effects of complications on trainees, including sadness (77.8%), anxiety(63.5%), guilt (69.8%) and embarrassment (63.5%). A total of 40.3% reported complications affected them outside of work. Only 60.9% felt well supported. Only 22.2% were offered formal support. In addition, 66.7% have witnessed another trainee struggle after a complication. Only 15.6% felt their training programme adequately prepares them to deal with the emotional impact of complications. Conclusions Adverse effects of complications on Trauma and Orthopaedic trainees are a prevalent issue. There are no ubiquitous formal structures in place to support trainees affected by complications. Nonblame, informal debrief sessions were cited repeatedly as beneficial. Keywords: Complications; Trainees; Trauma; Orthopaedics

Advance care planning (ACP) is a process of discussion, reflection and communication, enabling planning for future medical treatment. Despite evidence of benefits of ACP to patients, families and the healthcare system, many die without an opportunity for such conversations, particularly those living with progressive non-malignant conditions. The Royal College of General Practitioners and Marie Curie Daffodil Standards launched in 2020 provide primary care with a structure for improving end-of-life care, including delivery of ACP. Proactive identification of patients is integral to the approach.We report on a quality improvement project which aimed to assess the take-up rate and acceptability in general practice of a timely and personalised ACP conversation using a 'What matters to you' (WMTY) framework, and to ensure that different diagnostic and demographic groups were included.Patients without previous ACP and potentially in the last year of life were offered an ACP conversation; a survey sought feedback.81% accepted the offer and in most cases, future care guidance was documented using the recognised format in Gloucestershire for recording ACP conversations, the Recommended Summary for Emergency Care and Treatment (ReSPECT) plan. Clinician and patient satisfaction was high.We concluded that an ACP discussion using a 'WMTY' format was highly acceptable to most. With recognised enablers in place and known barriers minimised, valuable personalised conversations occurred. Reframing the conversation to focus on how someone wants to live, while including their priorities for death, could alter how such conversations are perceived by clinicians and the public. It could remove negative associations (such as linking these conversations with an imminent death), which may increase motivation for all to initiate discussions.ACP conversations are evidenced best practice and could become routine in general practice with adjustments to practice processes and clinician education; the Daffodil Standards facilitate continued quality improvement.

Background The role of public involvement (PI) in healthcare research is growing in importance and it is imperative that researchers continuously reflect on how to promote the inclusion of patients and service users in the design and delivery of research. PI offers a mechanism for end-users to be involved planning, executing, and reporting research. Some patient groups, including people who have communication difficulties, may struggle to engage in the methods traditionally employed to promote PI engagement such as questionnaires and focus groups. Methods This article describes a longitudinal case-study of a PI group, consisting of people who have communication difficulties, for a patient-reported outcome development project. Creative methods, informed by the participatory design principles of enacting, seeing and doing, were introduced stepwise into seven PI meetings. Data from video and visual minutes were used to evaluate the impact of the methods, following each group. Feedback, in the form of verbal and visual outputs taken directly from group meeting minutes, along with vignettes evidenced the impact of the methods on the project and group members. Results Creative methods enabled the PI group members to successfully contribute in meetings, to interact dynamically and to engage with the aims and processes of the research project. Their involvement facilitated the development of accessible recruitment materials, informed data analysis and supported the dissemination of project outputs. Employing creative methods also enabled both PI group members and the academic team to reflect on their own roles within the research project and the impact that their active involvement in the PI group has had on their personal development and perspectives on research. Conclusion The impact of using creative methods in PI for this patient-reported outcome measure (PROM) development project improved collaboration and understanding between PI members and the academic team. The authentic engagement of people who have communication difficulties in PI generated a more accessible project in terms of both process and impact. Creativity has applicability beyond people whose communication is non-verbal; it should be harnessed by research teams to identify and breakdown barriers to involvement to develop outcome tools that reflect the diversity of our populations.

Background & aims: The Barrett's Oesophagus Surveillance Study (BOSS) was the first randomized study of surveillance. This study reports the costs and quality of life outcomes from the BOSS trial and models the outcomes and cost-effectiveness of surveillance beyond the follow-up period of the BOSS study. This trial showed similar stages and rates of esophageal cancer in both arms, but the regular surveillance arm did identify more high-grade dysplasia after a median of 12.8 years follow-up. Methods: We used a decision tree model based on results from BOSS to conduct a cost-effectiveness analysis of costs and quality-adjusted life years (QALYs). A Markov model was used to extrapolate costs and outcomes over a further 10 years after the trial had ended, representing a 22.8-year time horizon. The proportion with high-grade dysplasia and QALYs was derived from the randomized trial. Results: The total costs associated with 2-yearly surveillance was $5309 vs $3182 in the at-need arm. Total QALYs in the 2-yearly endoscopy arm were 8.647 compared with 8.629 in the at-need arm. Compared with at-need endoscopy, 2-yearly surveillance costs $115,563/QALY gained. In the sensitivity analyses around assumptions on the proportion of high-grade dysplasia that is undetected in the at-need endoscopy arm, surveillance had an incremental cost effectiveness ratio of $94,513/QALY for the best-case and $146,272/QALY for the worst-case scenario. Conclusion: Barrett's esophagus surveillance every 2 to 3 years is unlikely to be a cost-effective strategy. Guidelines should take this into account when deciding surveillance intervals.