Mary Alison Durand

Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis

Objective To evaluate the impact and cost effectiveness of a programme to transform adult critical care throughout England initiated in late 2000. Design Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6. Setting 96 critical care units in England. Participants 349 817 admissions to critical care units. Interventions Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity. Main outcome measures Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at £20 000 (

Are the Public Health Responsibility Deal alcohol pledges likely to improve public health? An evidence synthesis

33 170, €22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000. Results In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from £402 (

Measuring therapeutic attitude among drug workers.

667, €445) to £1096 (

The identification and management of substance misuse problems by general practitioners

1810, €1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear. Conclusion Substantial improvements in NHS critical care have occurred in England since 2000. While it is unclear which factors were responsible, collectively the interventions represented a highly cost effective use of NHS resources.

Health information on alcoholic beverage containers: has the alcohol industry's pledge in England to improve labelling been met?

AIMS The English Public Health Responsibility Deal (RD) is a public-private partnership involving voluntary pledges between industry, government and other actors in various areas including alcohol, and designed to improve public health. This paper reviews systematically the evidence underpinning four RD alcohol pledges. METHODS We conducted a systematic review of reviews of the evidence underpinning interventions proposed in four RD alcohol pledges, namely alcohol labelling, tackling underage alcohol sales, advertising and marketing alcohol, and alcohol unit reduction. In addition, we included relevant studies of interventions where these had not been covered by a recent review. RESULTS We synthesized the evidence from 14 reviews published between 2002 and 2013. Overall, alcohol labelling is likely to be of limited effect on consumption: alcohol unit content labels can help consumers assess the alcohol content of drinks; however, labels promoting drinking guidelines and pregnancy warning labels are unlikely to influence drinking behaviour. Responsible drinking messages are found to be ambiguous, and industry-funded alcohol prevention campaigns can promote drinking instead of dissuading consumption. Removing advertising near schools can contribute to reducing underage drinking; however, community mobilization and law enforcement are most effective. Finally, reducing alcohol consumption is more likely to occur if there are incentives such as making lower-strength alcohol products cheaper. CONCLUSIONS The most effective evidence-based strategies to reduce alcohol-related harm are not reflected consistently in the RD alcohol pledges. The evidence is clear that an alcohol control strategy should support effective interventions to make alcohol less available and more expensive.

A 55 kg paper mountain: The impact of new research governance and ethics processes on mental health services research in England

A reluctance of nonspecialists to work with drug and alcohol misusers have focused upon belief-based systems, including therapeutic commitment (TC) and situation-specific constraints. This paper describes the development and assessment of a theoretical model for nonspecialist drug workers, characterised as a synthesis of attitudinal and constraints explanations. A cohort of 189 nonspecialist drug workers completed self-report measures of overall TC and situational constraints scales. Predictive analysis of associations between TC, role security (RS), role requirements, and situational constraints was performed to explore direct and indirect effects. Such assessment allowed for the identification of a predictive process by which TC may be established, manipulated, and maintained. Levels of TC were found to be explained by the direct effects of self-esteem (SE), situational constraints, role support, and RS. Role support and situational constraints were also found to have indirect effects. Experience with working with drug users and education on drug-related issues were found to have predominantly indirect effects on TC via situational constraints and RS. Findings show the synthesised model to be partially supported. Implications for the development of a process-driven theoretical understanding of TC and situational constraints are discussed, and applied recommendations for training intervention are presented.

Diageo's 'Stop Out of Control Drinking' Campaign in Ireland: An Analysis.

Central policy has increasingly encouraged general practitioners to be involved in treating patients with problems of substance misuse. A postal questionnaire was sent to all 416 general practitioners in the South East London Health Authority area to explore the extent of their identification and management of patients who smoke, or misuse alcohol or illicit opiates. A high response rate (78%) was achieved over three waves. Most doctors reported asking their patients about smoking and drinking and offering advice where a problem is found. Two-thirds of the general practitioners reported having seen at least one opiate misusing patient in the previous four weeks. More than a quarter reported always or often prescribing medication such as methadone for opiate misusing patients. Our findings differ from previous surveys and suggest that general practitioners may be becoming more active in the treatment of patients with problems of substance misuse.

'Not quite Jericho, but more doors than there used to be'. Staff views of the impact of 'modernization' on boundaries around adult critical care services in England.

AIMS In the United Kingdom, alcohol warning labels are the subject of a voluntary agreement between industry and government. In 2011, as part of the Public Health Responsibility Deal in England, the industry pledged to ensure that 80% of products would have clear, legible health warning labelling, although an analysis commissioned by Portman found that only 57.1% met best practice. We assessed what proportion of alcohol products now contain the required health warning information, and its clarity and placement. DESIGN Survey of alcohol labelling data. SETTING United Kingdom. PARTICIPANTS Analysis of the United Kingdoms 100 top-selling alcohol brands (n = 156 individual products). MEASUREMENTS We assessed the product labels in relation to the presence of five labelling elements: information on alcohol units, government consumption guidelines, pregnancy warnings, reference to the Drinkaware website and a responsibility statement. We also assessed the size, colour and placement of text, and the size and colouring of the pregnancy warning logo. FINDINGS The first three (required) elements were present on 77.6% of products examined. The mean font size of the Chief Medical Officers (CMO) unit guidelines (usually on the back of the product) was 8.17-point. The mean size of pregnancy logos was 5.95 mm. The pregnancy logo was on average smaller on wine containers. CONCLUSIONS The UK Public Health Responsibility Deal alcohol labelling pledge has not been fully met. Labelling information frequently falls short of best practice, with font and logos smaller than would be accepted on other products with health effects.

Community Alcohol Partnerships with the alcohol industry: what is their purpose and are they effective in reducing alcohol harms?

Background: The guidelines about research ethics and research governance, implemented by the Department of Health, present new challenges to undertaking mental health service research within the National Health Service (NHS). Aims: This paper describes how these new ethical and research governance procedures have adversely affected three multi-centre mental health service research studies, funded by the Department of Health. Methods: The workload, time, and cost of meeting these requirements for each study is described. Conclusion: The implementation of Government guidance has resulted in a level of bureaucracy that threatens the future of the type of research that underpins policy development and service planning. For the researcher, the work involved in meeting these new requirements can be greater than the work of data collection, and for the trust, greater than the cost of participation in the research itself. The Department of Health has made recommendations to streamline the research ethics process. However this will not address the tension between research ethics systems and localized research governance procedures. Declaration of interest: None.

The number, deployment, activities and attitudes of specialist consultant addiction psychiatrists in England: A national survey

Background It has been argued that the alcohol industry uses corporate social responsibility activities to influence policy and undermine public health, and that every opportunity should be taken to scrutinise such activities. This study analyses a controversial Diageo-funded ‘responsible drinking’ campaign (“Stop out of Control Drinking”, or SOOCD) in Ireland. The study aims to identify how the campaign and its advisory board members frame and define (i) alcohol-related harms, and their causes, and (ii) possible solutions. Methods Documentary analysis of SOOCD campaign material. This includes newspaper articles (n = 9), media interviews (n = 11), Facebook posts (n = 92), and Tweets (n = 340) produced by the campaign and by board members. All material was coded inductively, and a thematic analysis undertaken, with codes aggregated into sub-themes. Results The SOOCD campaign utilises vague or self-defined concepts of ‘out of control’ and ‘moderate’ drinking, tending to present alcohol problems as behavioural rather than health issues. These are also unquantified with respect to actual drinking levels. It emphasises alcohol-related antisocial behaviour among young people, particularly young women. In discussing solutions to alcohol-related problems, it focuses on public opinion rather than on scientific evidence, and on educational approaches and information provision, misrepresenting these as effective. “Moderate drinking” is presented as a behavioural issue (“negative drinking behaviours”), rather than as a health issue. Conclusions The ‘Stop Out of Control Drinking’ campaign frames alcohol problems and solutions in ways unfavourable to public health, and closely reflects other Diageo Corporate Social Responsibility (CSR) activity, as well as alcohol and tobacco industry strategies more generally. This framing, and in particular the framing of alcohol harms as a behavioural issue, with the implication that consumption should be guided only by self-defined limits, may not have been recognised by all board members. It suggests a need for awareness-raising efforts among the public, third sector and policymakers about alcohol industry strategies.