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Press releases Saturday 10 March 2007
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(1) Parenting programme helps improve child behaviour and is likely to be value for money
(2) NHS walk-in centres do not cut GP waiting times
(3) Should NICE evaluate complementary medicine?
(4) Reforms needed to improve the care in the last phase of life
(1) Parenting programme helps improve child behaviour and is likely to be value for money
(A Pragmatic randomised controlled trial and cost effectiveness analysis of a parenting intervention in Sure Start services
for children at risk of developing conduct disorder)
http://www.bmj.com/onlinefirst_date.dtl
Research in Wales has demonstrated that the Incredible Years parenting programme, an evidence-based programme developed at the University of Washington, Seattle, is very effective in reducing the likelihood of children going on to develop behavioural problems in the UK.
The study is published on bmj.com today and is the first of its kind to demonstrate the effectiveness of the programme in a community setting.
Antisocial behaviour in young people is a growing problem. Around 5-10% of UK and US children aged 5-15 years present with clinically significant conduct disorders and the problem is highest in socially disadvantaged areas. Left untreated, up to 40% of children with early difficulties develop subsequent conduct disorder, including drug misuse, criminal and violent behaviour.
So researchers in North Wales set out to determine whether the Incredible Years programme, which teaches and develops parenting skills, could help prevent a child from developing conduct disorders.
The programme was delivered by existing Sure Start staff across North and Mid Wales. Sure Start is a government strategy aimed at providing parenting support for young children and their families in high-risk communities.
More than 150 parents from socially disadvantaged areas took part. All had children aged 3 and 4 years at risk of conduct disorder. Parents were either placed on the programme (12 weekly group sessions) or were put on a waiting list (controls).
Child behaviour and parenting skill were assessed at the start of the study and six months later both by parent report and by direct blind observation. Parents were also asked to self-rate their own feelings of depression, stress and ability to cope.
Children on the programme showed significantly reduced antisocial and hyperactive behaviour, and increased self-control, compared to control children. Parents reported a reduction in stress and depression levels and improved parenting skills.
The authors say this study holds "important lessons for the UK government because, unlike the disappointing results from the national evaluation of Sure Start, it shows that choosing an evidence-based programme ... can achieve remarkable outcomes in high risk children whose parents generally fail to engage with services."
They conclude: "It is important that Government commission effective services for high-risk conduct disordered children. They deserve evidence-based programmes, as do the public, who pay a high price for services and for the other costs of antisocial behaviour."
In a separate paper, the researchers looked at the cost-effectiveness of the programme. Costs were measured from a public sector perspective including health, special educational and social services, and these were considered against the outcome of improved child behaviour based on parent report using the Eyberg Child Behaviour Index (ECBI), a commonly used measure of child behaviour and the primary outcome measure reported in the main study.
They calculated that it would cost ±1344 to bring the average child on the programme to below the clinical cut-off point and ±5486 to bring the child with the highest ECBI score to below the clinical cut-off point. The programme also appeared to be more cost effective in children at highest risk of developing conduct disorder.
This parenting programme involves a modest additional cost and demonstrates strong clinical effect, suggesting it would represent good value for money for public spending, they conclude.
Contact:
Judy Hutchings, Research Director, School of Psychology, University of Wales Bangor, Wales, UK
Email: j.hutchings@bangor.ac.uk
(2)
NHS walk-in centres do not cut GP waiting times
(Impact of NHS walk-in centres on primary care access times: ecological study)
http://www.bmj.com/onlinefirst_date.dtl
There is no evidence that walk-in centres shorten waiting times to see a general practitioner, say researchers in a BMJ study published online today.
NHS walk-in centres are primarily nurse-led, have wide opening hours and provide information and treatment for minor conditions without the need for appointments. One of their aims is to relieve the pressure on access to primary care by freeing up time during normal practice surgery hours for patients who need to see their GP.
There are concerns that they increase demand rather than reduce the workload for primary care, but the evidence to date is inconclusive.
The study took place from April 2003 to December 2004 and involved 2,509 general practices in 56 primary care trusts in England, and 32 walk-in centres within 3km of at least one of these practices. Data collection included distance from a practice to the nearest walk-in centre.
There was a clear increase in the percentage of practices achieving the target waiting time of less than 48 hours to see a GP over the 21 month study period, but there was no evidence that walk-in centres contributed to shorter waiting times. Waiting times were longer in more deprived areas and shorter in larger practices.
These results are consistent with a previous study that found no effect of a single walk-in centre on workload or waiting times in nearby practices, say the authors.
There are a number of possible explanations for this apparent lack of effect. Walk-in centres may have created more demand by seeing patients who would otherwise not have attended for health care. Alternatively, duplication of services could have arisen due to patients being referred back to their GPs.
Walk-in centres are part of an increasingly complex network of primary care and first contact services for health care and may extend and at times potentially duplicate rather than offer an alternative for care provided by GPs, they say.
±We found no evidence that walk-in centres shortened primary care access waiting times and our study does not support the use of walk-in centres for this purpose.±
Contact:
Dr Ravi Maheswaran, Senior Clinical Lecturer in Public Health Medicine, School of Health and Related Research, University
of Sheffield, Sheffield, UK
Email: r.maheswaran@sheffield.ac.uk
(3)
Should NICE evaluate complementary medicine?
(Head to Head: Should NICE evaluate complementary and alternative medicine?)
http://www.bmj.com/cgi/content/full/334/7591/506
Demand for complementary and alternative medicine is high despite limited evidence. In this week±s BMJ, researchers go head to head over whether the National Institute for Health and Clinical Excellence (NICE) should review these therapies.
NICE was set up as an independent body by the UK government in 1999, charged with getting the best from NHS resources. It examines the value of treatments and decides whether they should be used in the NHS.
Around half of general practitioners provide access to complementary medicine, and two thirds of Scottish general practitioners prescribe herbal or homoeopathic medicines, so a thorough review by NICE would benefit the NHS and patients, argue Professor Linda Franck and colleagues.
Some people within conventional medicine remain deeply convinced that alternative medicine cannot have any possible benefit, but this is all the more reason that these therapies should be rigorously evaluated, they argue.
They believe that failure to evaluate complementary therapies also leads to health inequalities because of uneven access and missed opportunities. For example, as complementary therapies are often relatively cheap, if shown to be effective they could save money currently spent on costly drugs.
Complementary and alternative therapies deserve a full evaluation from NICE and, if the evaluation is favourable, they should be adopted either on their own or integrated with conventional medicine, they conclude.
But Professor David Colquhoun argues that NICE cannot afford to re-examine evidence that has shown little benefit.
He points out that NICE already have alternative treatments in several of their reports and, in all these cases, they have found no good evidence for anything more than placebo effects.
And it is not necessary to take the word of sceptics about the lack of evidence. The more honest advocates of complementary and alternative medicine admit it themselves, he adds.
None of this is intended to deny the important role of supportive and palliative care for patients for whom that is the best that can be done, he says. But there is no need to subscribe to the early 19th century pseudoscientific hocus pocus of homoeopathy to treat sick patients sympathetically and holistically.
And there is no need for NICE to spend time and money coming to that conclusion when it has more important things to do, he concludes.
Contacts:
Professor Linda Franck, University College London Institute of Child Health, London, UK
Tel (via Great Ormond St Hospital/Institute of Child Health Press Office):
Email: l.franck@ich.ucl.ac.uk
David Colquhoun, Professor of Pharmacology, University College London, UK
Email: d.colquhoun@ucl.ac.uk
(4) Reforms needed to improve the care in the last phase of life
(Getting services right for those sick enough to die)
http://www.bmj.com/cgi/content/full/334/7591/511
Reforms are urgently needed to improve the health needs of people in the last phase of life, say doctors in this week±s BMJ.
Our health care systems do not reliably meet the needs of people living with serious illness in the last phase of life, write Sydney Dy and Joanne Lynn, two palliative care doctors based in the United States.
Even though contrary evidence is all around us, we use language ± and build health care systems ± as if disability and ill health were aberrations, rather than an expected phase that lasts months or years nearer the end of most of our lives, they say.
Yet only a few per cent of people in developed countries now die suddenly. Traditional hospital and surgical services no longer match most patients± serious chronic illnesses, a fact that calls for substantial restructuring.
And since the numbers of people living with serious chronic conditions in old age will double within the next two decades in the United States and many other countries, finding sustainable ways to improve comfort and meaningfulness in this last phase of life has become a priority.
Patients coming to the end of life tend to follow one of three trajectories, with different priorities and needs, they explain. For example, patients with a short period of decline most need continuity of care and aggressive symptom management. Those with chronic organ system failure most need disease management and advance planning, while those with long-term dementia or frailty most need support services rather than intensive treatment.
Customising and reengineering care to match the needs, rhythms, and situations of these three trajectories offers a promising way to improve outcomes for patients sick enough to die, they say. If a community can build a care system that reliably serves patients in each trajectory in their area, then almost everyone there could count on good care in the last phase of life. This might create a reliable care system for this fragmented and inefficient part of the health care picture.
Contact:
Sydney Dy, Assistant Professor of Health Policy and Management, Johns Hopkins University, USA
Mobile:
Email: sdy@jhsph.edu
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