BACKGROUND:Skin cancer comprises half of all cancers in England and Wales. Most skin cancers can be prevented with safer sun exposure. As over exposure as a child can greatly increase future skin cancer risk, early and accessible sun safety education and promotion of sun safe behaviours is critical. Scientists agree there is no such thing as a 'safe tan', yet the public, including children, often have positive perceptions of tanned skin. To protect against future skin cancer, it is important to understand and address these misconceptions. The Curriculum for Wales with its area for Health and Well-being, and autonomy for schools in designing curriculum content, presents an ideal way to facilitate this exploration. AIMS:Gather data regarding perceptions towards tanning to explore the perceived effects of a tan on health.Inform the development and testing of an educational toolkit for integration within the Curriculum for Wales to encourage positive health behaviours and attitudes of school children towards tanning and sun exposure. METHODS:SunChat is a mixed methods exploratory study comprising three work streams: Workshops with school children to understand their perceptions on tanning.An online multiple-choice survey with parents/carers to understand perceptions, attitudes and behaviours towards tanning both for themselves and their children.An informal focus group with primary school educators to explore challenges in engaging with the school community around the Health and Well-being Area in the Curriculum for Wales. DISCUSSION:To date, there has been no work in Wales exploring children's, parents/carers', and educators' perceptions of tanning and how healthier attitudes can be encouraged. This study will engage with participants to scope current perceptions on tanning and the perceived effects tanning has on health. Findings will feed into future toolkit and curriculum development for health in schools in Wales and beyond.

BACKGROUND:Schools with formal sun safety polices generally show better sun safety practices than schools without.OBJECTIVES:To understand the extent to which Welsh primary schools have sun safety policies; to identify the key characteristics of policies; to assess whether policy adoption varies by school characteristics; and to consider what support schools need to develop sun safety policies.METHODS:An online multiple-choice survey on sun safety was distributed to all 1241 primary schools in Wales.RESULTS:In total, 471 (38.0%) schools responded. Of these, 183 (39.0%) reported having a formal sun safety policy. Welsh medium schools (P = 0.036) and schools in North Wales (P = 0.008) were more likely to report having a policy. Schools with a higher percentage of pupils receiving free school meals (P = 0.046) and with lower attendance rates (P = 0.008) were less likely to report having a sun safety policy. The primary reasons for schools not having a policy included being 'not aware of the need' (34.6%); 'need assistance with policy or procedure development' (30.3%); and 'not got around to it just yet' (26.8%).CONCLUSIONS:With less than half of schools reporting a sun safety policy and variation in the presence/absence of a policy by school characteristics, our survey revealed inconsistency in formal sun safety provision in Welsh schools. The findings also suggest that schools are unaware of the importance of sun safety and need support to develop and implement policies. This snapshot of the current situation in primary schools in Wales provides a basis upon which the comprehensiveness, effectiveness and implementation of sun safety policies can be further evaluated.

Skin cancer rates are on the rise globally. School sun safety programmes are recommended by the World Health Organization to reduce the risk of future skin cancer at the population level; however, these are encouraged but not mandated in Wales. Our study aimed to explore current sun protection practices and sun safety education in primary schools in Wales, and whether these are linked to the existence of a formal sun safety policy. To do this, we distributed an online survey to all 1241 Welsh primary schools asking about sun safety practices, education and formal policies. In total, 471 (38.0%) schools responded to our survey, with the characteristics of responding schools generally matching the profile of schools in Wales. A minority (22, 4.7%) of responding schools reported they had sufficient shade for most activities. In the spring and summer terms almost two-thirds of schools encourage hat wearing (304, 64.8% of available data) and suncream (296, 63.2%). While nearly all schools reported that parents were encouraged to apply suncream to students before school (449, 95.7%), there was wide variation in other suncream application practices. Less than one-third of schools (129, 29.0%) reported that they include sun protection education in the curriculum in every year group, with 11.7% (52) including this in certain years only. Schools with a formal sun safety policy were more likely to report more comprehensive sun protection practices, including having sufficient shade [odds ratio (OR) 1.51, 95% confidence interval (CI) 1.04–2.19; P = 0.03], having spare hats for pupils to wear (OR 1.59, 95% CI 1.07–2.37; P = 0.02), providing guidance for staff (OR 5.87, 95% CI 3.05–11.3; P < 0.001), encouraging them to model sun safe behaviours (OR 1.82, 95% CI 1.18–2.80; P = 0.007) and teaching sun protection education as part of the curriculum in every year group (OR 2.56, 95% CI 1.76–3.71; P < 0.001). The existence of a formal policy did not seem to affect a school’s practice with respect to suncream. While in most cases, the existence of a formal policy suggests more comprehensive sun protection practices and education in schools in Wales, sun protection measures and education need improvement across the primary school sector to reverse rising skin cancer rates.

Dear Editor, With an average 156 days of rain a year in the United Kingdom (UK), it's no surprise that when the sun comes out, the British approach is to 'make the most of it'. Spend a sunny day at any UK beach and you'll see several sunburns at the end of the day. But summer is fast approaching here, and dermatologists and healthcare professionals continue to stress that skin cancer prevention is of upmost importance.1 Skin cancer, including melanoma and non-melanoma (keratinocyte), is increasing rapidly at a rate of 8% annually and now comprises half of all cancers in England and Wales.1 Accounting for an increasing proportion of workload, the disease is impacting dermatology services, causing care for other skin conditions to suffer, and waiting lists to grow. However, with estimates that 86% of melanomas are preventable with less sun exposure2 there is hope. Most skin cancers result from excess ultraviolet (UV) light exposure and severe sunburn as a child greatly increases risk of future skin cancer.3 Combine this with the fact that childhood is when individuals start to develop responsibility for health-related behaviours including attitudes to tanning, teaching children about enjoying the sun safely and skin cancer prevention makes sense. In line with this, supported by a recent systematic review which showed educational programmes appeared effective for improving sun protection outcomes in children under 18,4 major health bodies including World Health Organization, British Association of Dermatologists and National Institute for Health and Care Excellence, all recommend sun safety education and guidance in schools. Yet while prevention and education are clearly key, in the UK both sun safety knowledge and behaviour need to increase if future skin cancer rates are to decrease.5 Additionally, there has been very little research done in UK primary schools4 perhaps given the variable weather and the particular challenges in promoting sun safety in a 'maritime climate'. In England, it's now a statutory requirement to teach primary school children about safe exposure to the sun. However, in Wales, it's a different story. Despite a strong policy focus on prevention activities, and calls from both the public and charities that schools have clear plans in place, in Wales, it is still not mandatory to teach children how to enjoy the sun safely and there is no blanket guidance to keep children protected. Informal discussions with several Healthy Schools Co-ordinators based at Public Health Wales suggest schools in Wales would welcome any additional support in this key area. Unfortunately, while Cancer Research UK and the Wales-based Tenovus Cancer Care previously offered resources and guidance to schools, both charities have cut their sun safety education and prevention activities due to other priorities. The English-based charity Skcin has a free sun safe schools accreditation scheme available to schools in Wales, although their resources are not available in Welsh which may pose a deterrent to registration, especially for Welsh speaking schools. While many will argue that the risks of a child getting sunburnt at school are minimal, the benefits of a sun safety policy in schools reach beyond the classroom. Due to the increased risk of damage from sun exposure at a young age children should be free to enjoy the weather safely, wherever they are. Providing children with a sun safe school environment, educating them on sun protective behaviours and encouraging healthy attitudes towards tanning from an early age are all ways to empower them to take control over their health. We have recently won funding from Health and Care Research Wales for Sunproofed, a 2-year scoping study6 to better understand the landscape of skin cancer prevention in primary schools in Wales. Bringing together both quantitative and qualitative methods and using anonymised, routine data, we will discover what if any, sun safety policies currently exist, the benefits, barriers and facilitators to teaching sun safety in school and what support schools need in this area. A key output of this research will be to use study findings to co-produce guidance on best methods for implementing sun safety policies in Welsh schools. While we acknowledge the long-term benefits of any intervention that tackles skin cancer prevention will take years to become apparent, we are pleased Welsh Government have recognised the importance of this work. Teaching children how to be safe in the sun has the potential to improve sun protection outcomes,4 potentially reversing growing rates of skin cancer and saving both resources and lives. And when the rain stops in Wales? Young people will be well placed to protect themselves. Julie Peconi: Conceptualization (lead); Funding acquisition (lead); Project administration (lead); Writing – original draft (lead). Greg Fegan: Conceptualization (supporting); Funding acquisition (supporting); Project administration (supporting); Writing – review & editing (equal). Rachel Abbott: Conceptualization (supporting); Funding acquisition (supporting); Project administration (supporting); Writing – review & editing (equal). Health and Care Research Wales [HRG-20-1708(P)]. None to declare. Although this letter focuses on our opinion, the study we reference in the letter, Sunproofed has received ethical approval from Swansea University's Medical School Research Ethics Sub-Committee. Not applicable.

Background Skin cancer, including melanoma and non-melanoma (keratinocyte), is increasing in incidence in the UK. Accounting for half of all cancers in England and Wales, the disease significantly impacts overstretched dermatology services. Research suggests that 86% of melanoma is preventable with modified sun exposure. Educating children about sun safety in schools can help prevent skin cancer and is recommended by major health organisations. In England, teaching sun safety in primary schools is compulsory, while in Wales this is left to school discretion. Aims Understand how primary schools in Wales are responding to growing skin cancer rates and explore the effectiveness of sun safety policies in schools on knowledge and behaviour. Methods Sunproofed is a mixed-methods scoping study comprising 5 work packages (WP) using survey and routine electronic health record (EHR) data supplemented by qualitative case studies. Objective(s) are to: WP1: Discover if primary schools in Wales have sun safety policies; policy characteristics; determine factors that may influence their presence and identify areas where schools need support. WP2: Determine what EHR data is available regarding the incidence of sunburn in primary school children and the feasibility of using this data to evaluate the impact of sun safety policies. WP3: Understand the impact of sun safety policies on sun-safe knowledge and behaviour amongst children, parents, teachers, and school management; identify barriers and facilitators to schools implementing sun safety policies. WP4: Co-produce guidance regarding sun safety policies and best methods for implementation in schools. WP5: Disseminate guidance and findings widely to ensure impact and uptake. Discussion Skin cancer rates are increasing in the UK, straining limited resources. Sunproofed has the potential to inform the development of future prevention activities, both in Wales and beyond. This could reduce the number of skin cancer cases in the future and keep people healthier for longer.

Background Over half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well. Objectives We aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia. Design We undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study. Setting The national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations. Participants People aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent. Main outcome measures The trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence. Methods Owing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study. Results Our reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups. Limitations Our chosen outcome measures may not reflect subtle outcomes valued by people with dementia. Conclusions Several approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective. Future work Further work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures. Study registration Current Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information.

Objective To estimate the effect of deprivation on the demand for calls to National Health Service Direct Wales (NHSDW) controlling for confounding factors. Design Study of routine data on over 400 000 calls to NHSDW using multiple regression to analyse the logarithms of ward-specific call rates across Wales by characteristics of call, patient and ward, notably the Welsh Index of Multiple Deprivation. Setting 810 electoral wards with average population of 3300, defined by 1998 administrative boundaries. Population All calls to NHSDW between January 2002 and June 2004. Main outcome measures We used ward populations as denominators to calculate the rates of three categories of calls: calls seeking advice, calls seeking information and all calls combined. Results Confounding variables explained 31% of variation in advice call rates, but only 14% of variation in information call rates and in all call rates (all significant at 0.1% level). However, deprivation was only a statistically significant predictor of information call rates. The proportion of the ward population categorised as ‘white’ was a highly significant predictor of all three call rates. For advice calls and combined calls, rates decreased highly significantly with the proportion of those who called the service for themselves. Information call rates were higher on weekdays and highest on Mondays, while advice call rates were highest on Sundays. Conclusions Deprivation had no consistent effect on demand for the service and the relationship needs further exploration. While our data may have underestimated the ‘need’ of deprived patients, they yield no evidence that policy-makers should seek to improve demand from those patients. However, we found differences in the way callers use advice and information calls. Previously unexplored variables that help to predict ward-specific call rates include: ethnicity, day of the week and whether patients made the calls themselves.

Within the UK, Wales has among the highest rates of skin cancer annually and skin cancer diagnosis rates have increased 63% in 10 years1 . The charity Skin Care Cymru (SCCym) provides a voice for skin health in Wales. Working with volunteers from an advertising agency and a communications company, in March 2017, SCCym launched a public health campaign to educate the public about ultraviolet radiation and encourage sun safe behaviour. A cartoon symbol of a lobster to represent sunburn replaced the usual red dragon on the Welsh flag, Figure 1. The hashtag #DontBeALobster was used to promote the campaign. This article is protected by copyright. All rights reserved.

BackgroundCommon memory aids for people with dementia at home are recommended. However, rigorous evaluation is lacking, particularly what guidance or support is valued.ObjectiveTo investigate effects of memory aids and guidance by dementia support practitioners (DSPs) for people in early-stage dementia through a pragmatic, randomised controlled trial.MethodsOf 469 people with mild-to-moderate dementia and their informal carers, 468 were randomised to a DSP with memory aids or to usual care plus existing dementia guide. Allocation was stratified by Trust/Health Board; time since first attendance at memory service; gender; age; and living with primary carer or not. Primary outcome was Bristol Activities of Daily Living Scale (BADLS) Score at 3 and 6 months (primary end-point). Secondary outcomes for people with dementia: quality of life (CASP-19; DEMQOL); cognition and functioning (Clinical Dementia Rating Scale; S-MMSE); capability (ICECAP-O); social networks (LSNS-R); and instrumental daily living activities (R-IDDD). Secondary outcomes for carers: psychological health (GHQ-12); sense of competence (SSCQ).ResultsDSPs were successfully trained, compliance was good and welcomed by participants. Mean 6 months BADLS Score increased to 14.6 (SD: 10.4) in intervention and 12.6 (SD: 8.1) in comparator, indicative of greater dependence in the activities of daily living. Adjusted between-group difference was 0.38 (95% CI: −0.89 to 1.65, p=0.56). Though this suggests greater dependency in the intervention group the difference was not significant. No differences were found in secondary outcomes.ConclusionsThis intervention did not maintain independence in the activities of daily living with no improvement in other outcomes for people with dementia or carers.Trial registration numberCurrent Controlled TrialsISRCTN12591717.

ABSTRACTBackground:Dementia is a major health problem with a growing number of people affected by the condition, both directly and indirectly through caring for someone with dementia. Many live at home but little is known about the range and intensity of the support they receive. Previous studies have mainly reported on discrete services within a single geographical area. This paper presents a protocol for study of different services across several sites in England. The aim is to explore the presence, effects, and cost-effectiveness of approaches to home support for people in later stage dementia and their carers.Methods:This is a prospective observational study employing mixed methods. At least 300 participants (people with dementia and their carers) from geographical areas with demonstrably different ranges of services available for people with dementia will be selected. Within each area, participants will be recruited from a range of services. Participants will be interviewed on two occasions and data will be collected on their characteristics and circumstances, quality of life, carer health and burden, and informal and formal support for the person with dementia. The structured interviews will also collect qualitative data to explore the perceptions of older people and carers.Conclusions:This national study will explore the components of appropriate and effective home support for people with late stage dementia and their carers. It aims to inform commissioners and service providers across health and social care.

Background Emergency calls are frequently made to ambulance services for older people who have fallen, but ambulance crews often leave patients at the scene without any ongoing care. We evaluated a new clinical protocol which allowed paramedics to assess older people who had fallen and, if appropriate, refer them to community-based falls services. Objectives To compare outcomes, processes and costs of care between intervention and control groups; and to understand factors which facilitate or hinder use. Design Cluster randomised controlled trial. Participants Participating paramedics at three ambulance services in England and Wales were based at stations randomised to intervention or control arms. Participants were aged 65 years and over, attended by a study paramedic for a fall-related emergency service call, and resident in the trial catchment areas. Interventions Intervention paramedics received a clinical protocol with referral pathway, training and support to change practice. Control paramedics continued practice as normal. Outcomes The primary outcome comprised subsequent emergency health-care contacts (emergency admissions, emergency department attendances, emergency service calls) or death at 1 month and 6 months. Secondary outcomes included pathway of care, ambulance service operational indicators, self-reported outcomes and costs of care. Those assessing outcomes remained blinded to group allocation. Results Across sites, 3073 eligible patients attended by 105 paramedics from 14 ambulance stations were randomly allocated to the intervention group, and 2841 eligible patients attended by 110 paramedics from 11 stations were randomly allocated to the control group. After excluding dissenting and unmatched patients, 2391 intervention group patients and 2264 control group patients were included in primary outcome analyses. We did not find an effect on our overall primary outcome at 1 month or 6 months. However, further emergency service calls were reduced at both 1 month and 6 months; a smaller proportion of patients had made further emergency service calls at 1 month (18.5% vs. 21.8%) and the rate per patient-day at risk at 6 months was lower in the intervention group (0.013 vs. 0.017). Rate of conveyance to emergency department at index incident was similar between groups. Eight per cent of trial eligible patients in the intervention arm were referred to falls services by attending paramedics, compared with 1% in the control arm. The proportion of patients left at scene without further care was lower in the intervention group than in the control group (22.6% vs. 30.3%). We found no differences in duration of episode of care or job cycle. No adverse events were reported. Mean cost of the intervention was £17.30 per patient. There were no significant differences in mean resource utilisation, utilities at 1 month or 6 months or quality-adjusted life-years. In total, 58 patients, 25 paramedics and 31 stakeholders participated in focus groups or interviews. Patients were very satisfied with assessments carried out by paramedics. Paramedics reported that the intervention had increased their confidence to leave patients at home, but barriers to referral included patients’ social situations and autonomy. Conclusions Findings indicate that this new pathway may be introduced by ambulance services at modest cost, without risk of harm and with some reductions in further emergency calls. However, we did not find evidence of improved health outcomes or reductions in overall NHS emergency workload. Further research is necessary to understand issues in implementation, the costs and benefits of e-trials and the performance of the modified Falls Efficacy Scale. Trial registration Current Controlled Trials ISRCTN60481756 and PROSPERO CRD42013006418. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 21, No. 13. See the NIHR Journals Library website for further project information.

BACKGROUND:In the UK, National Health Service Direct Wales (NHSDW) uses computerised decision support software to advise patients on appropriate care. However, the effect of deprivation on the advice given is not known. We aimed to estimate the effect of deprivation on advice given by nurses in NHSDW adjusting for confounding variables.METHODS:We included 400 000 calls to NHSDW between January 2002 and June 2004. We used logistic regression to model the effect of deprivation on advice given by nurses in response to calls seeking advice or information. We analysed two outcomes: receiving advice to phone 999 emergency care rather than to seek other care and receiving advice to seek care face to face rather than self-care.RESULTS:After adjustment for covariates, an increase in deprivation from one-fifth of the distribution to the next fifth increased by 13% the probability that those calling for advice rather than information received advice to phone 999 (OR 1.127; 95% CI from 1.113 to 1.143). Deprivation increased the corresponding probability of being advised to seek care face to face rather than self-care by 5% (OR 1.049; 95% CI from 1.041 to 1.058) within advice calls and by 3% (OR 1.034; 95% CI from 1.022 to 1.047) within information calls.CONCLUSIONS:Deprivation increased the chance of receiving more urgent advice, particularly advice to call 999. While our dataset may underestimate the 'need' of deprived patients, it yields no evidence of major inequity in advice given to these patients.

STUDY OBJECTIVE:We aim to determine clinical and cost-effectiveness of a paramedic protocol for the care of older people who fall.METHODS:We undertook a cluster randomized trial in 3 UK ambulance services between March 2011 and June 2012. We included patients aged 65 years or older after an emergency call for a fall, attended by paramedics based at trial stations. Intervention paramedics could refer the patient to a community-based falls service instead of transporting the patient to the emergency department. Control paramedics provided care as usual. The primary outcome was subsequent emergency contacts or death.RESULTS:One hundred five paramedics based at 14 intervention stations attended 3,073 eligible patients; 110 paramedics based at 11 control stations attended 2,841 eligible patients. We analyzed primary outcomes for 2,391 intervention and 2,264 control patients. One third of patients made further emergency contacts or died within 1 month, and two thirds within 6 months, with no difference between groups. Subsequent 999 call rates within 6 months were lower in the intervention arm (0.0125 versus 0.0172; adjusted difference -0.0045; 95% confidence interval -0.0073 to -0.0017). Intervention paramedics referred 8% of patients (204/2,420) to falls services and left fewer patients at the scene without any ongoing care. Intervention patients reported higher satisfaction with interpersonal aspects of care. There were no other differences between groups. Mean intervention cost was $23 per patient, with no difference in overall resource use between groups at 1 or 6 months.CONCLUSION:A clinical protocol for paramedics reduced emergency ambulance calls for patients attended for a fall safely and at modest cost.

Background Health services research is expected to involve service users as active partners in the research process, but few examples report how this has been achieved in practice in trials. We implemented a model to involve service users in a multi-centre randomised controlled trial in pre-hospital emergency care. We used the generic Standard Operating Procedure (SOP) from our Clinical Trials Unit (CTU) as the basis for creating a model to fit the context and population of the SAFER 2 trial. Methods In our model, we planned to involve service users at all stages in the trial through decision-making forums at 3 levels: 1) strategic; 2) site (e.g. Wales; London; East Midlands); 3) local. We linked with charities and community groups to recruit people with experience of our study population. We collected notes of meetings alongside other documentary evidence such as attendance records and study documentation to track how we implemented our model. Results We involved service users at strategic, site and local level. We also added additional strategic level forums (Task and Finish Groups and Writing Days) where we included service users. Service user involvement varied in frequency and type across meetings, research stages and locations but stabilised and increased as the trial progressed. Conclusion Involving service users in the SAFER 2 trial showed how it is feasible and achievable for patients, carers and potential patients sharing the demographic characteristics of our study population to collaborate in a multi-centre trial at the level which suited their health, location, skills and expertise. A standard model of involvement can be tailored by adopting a flexible approach to take account of the context and complexities of a multi-site trial. Trial registration Current Controlled Trials ISRCTN60481756 . Registered: 13 March 2009

The responsibility for health and well-being in the United Kingdom (UK) falls to the National Health Service (NHS). The NHS was established in 1948 to promote “the establishment of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness” (NHS Act, 1946). The service varies from health-care provision in other Western countries, in that responsibility falls to the government in power.37 As a result of changes in political administration and alongside changes in health, an aging population and advances in technology, over the past 60 years the NHS has experienced many adaptations, not only in the manner of delivery of health-care services, but also in the structure and organization of these services.

BACKGROUND:Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology--hand-held computers with computerised clinical decision support (CCDS) software--to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services.METHODS/DESIGN:Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial.Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders.The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically.DISCUSSION:Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services.In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen.TRIAL REGISTRATION:ISRCTN10538608.

BACKGROUND:An evaluation of NHS Direct Wales (NHSDW), a national telephone-based healthcare advice and information service, was undertaken. A key objective was to describe the actions of callers and assess the appropriateness of advice and healthcare contacts made following calls, results of which are reported here.METHODS:Postal questionnaires were sent to consecutive callers to NHSDW in May 2002 and February 2004 to determine 1) callers' actions following calls and 2) their views about the appropriateness of: advice given; and when to seek further care. An independent clinical panel agreed and applied a set of rules about healthcare sites where examinations, investigations, treatments and referrals could be obtained. The rules were then applied to the subsequent contacts to healthcare services reported by respondents and actions were classified in terms of whether they had been necessary and sufficient for the care received.RESULTS:Response rates were similar in each survey: 1033/1897 (54.5%); 606/1204 (50.3%), with 75% reporting contacting NHSDW. In both surveys, nearly half of all callers reported making no further healthcare contact after their call to NHSDW. The most frequent subsequent contacts made were with GPs.More than four fifths of callers rated the advice given - concerning any further care needed and when to seek it - as appropriate (further care needed: survey 1: 673/729, 82.3%; survey 2: 389/421, 92.4%; when to seek further care - survey 1: 462/555, 83.2%; survey 2: n = 295/346, 85.3%). A similar proportion of cases was also rated through the rule set and backed up by the clinical panel as having taken necessary and sufficient actions following their calls to NHSDW (survey 1: 624/729, 80.6%; survey 2: 362/421, 84.4%), with more unnecessary than insufficient actions identified at each survey (survey 1: unnecessary 132/729, 17.1% versus insufficient 11/729, 1.4%; survey 2: unnecessary 47/421, 11.0% versus insufficient 14/421, 3.3%).CONCLUSION:Based on NHSDW caller surveys responses and applying a transparent rule set to caller actions a large majority of subsequent actions were assessed as appropriate, with insufficient contacts particularly infrequent. The challenge for NHSDW is to reduce the number of unnecessary contacts made following calls to the service, whilst maintaining safety.

ABSTRACT Plants and pollinators are experiencing parallel declines worldwide, despite theory predicting that pollination networks should withstand disturbance due to redundancy of pollinators, rarity of interactions between specialists, and flexible pollinator foraging behavior (rewiring). Experiments evaluating the stability of plant-pollinator networks may help resolve this incongruity but remain uncommon. In this study, we simulated the extirpation of a hummingbird-pollinated understory plant, Heliconia tortuosa, from tropical forest fragments using a replicated Before-After-Control-Impact experimental design while quantifying hummingbird space use (383 hummingbird captures and 72 radio-tagged individuals), floral visitation rates (6,759 visitations from 20,725 observation hours), and plant pollination success (529 flowers). To complement this experimental approach, we also examined these responses across a natural gradient in H. tortuosa density. We expected that declines of H. tortuosa would either result in (a) network collapse, in which hummingbirds vacate fragments and compromise the reproductive success of other flowering plants, or (b) increased hummingbird reliance on alternative resources, leading to sustained fragment use. We also hypothesized that landscape and local context (i.e., connectivity to additional forest area and alternative resource abundance) could mediate hummingbird responses to H. tortuosa declines; for example, connectivity could facilitate hummingbird visitation to areas of reduced food availability. In our removal experiment, hummingbird persistence and plant pollination success were remarkably resistant to loss of H. tortuosa, a locally common plant species representing >40% of the available nectar resources on average. However, naturally low H. tortuosa densities were associated with reduced floral visitation rates and decreased pollination. Although landscape context (connectivity) led to higher hummingbird abundance, we found little evidence that connectivity or resource availability mediated hummingbird responses to declines in H. tortuosa availability. The exact mechanisms enabling short-term hummingbird persistence after resource removal remain unclear, as we did not discover evidence of rewiring. Physiological adaptations (e.g., torpor and insectivory), may have contributed to hummingbird resilience, perhaps alongside high movement abilities that facilitated visitation to spatially dispersed floral resources. With the important caution that short-term experiments may not realistically emulate natural extinction processes, our study provides partial support for theoretical predictions that pollination networks may be relatively robust to plant species loss.

Background A recent national review of English ambulance services, Taking Healthcare to the Patient: Transforming NHS Ambulance Services, 1 published by the Department of Health, recommended that pre-hospital care research topics should be prioritised to ensure that service provision and development are evidence based wherever possible and that limited available funds are targeted to the most pressing needs. Study objectives To identify gaps in research evidence related to delivery of pre-hospital care; and to rank topics in order of priority for research. Methods Research priorities were initially identified by delegates at the UK Ambulance Service Association's annual conference, AMBEX 2006. An examination of research reviews in pre-hospital care identified other research evidence gaps. Relevant websites, databases and review bibliographies were also searched. Management, service delivery and treatment recommendations in UK policy/guidance documents published since 2000 were matched to research evidence. A list of evidence gaps was circulated in a Delphi-style three-round consultation to experts in pre-hospital care, including clinicians, managers and researchers. Round 1 confirmed/identified research gaps; Round 2 focussed on ranking topics; and Round 3 reviewed the scores and provided an option to rescore. Scores were analysed using SPSS. Results Ninety-six research issues were identified for circulation and prioritisation from 52 reviews and expert consultation and these were matched against 30 policy and guidance documents. Forty people participated in the Delphi exercise. The subject receiving highest priority for research was the development of new performance measures other than emergency ambulance response times. Other highly ranked priorities included treatment of stroke, cardiac conditions, children and people who self-harm; alternatives to Accident and Emergency (A&E) treatment; patient information sharing across care providers; access issues; decision support systems; and demand management systems for pre-hospital care. These priorities reflect three key issues: measuring activity to benefit patients; development of safe non-A&E care; and providing appropriate evidence-based clinical care in the pre-hospital environment. Implications There are many evidence gaps related to current pre-hospital policy and practice including management, clinical and service delivery issues. This Delphi consultation combines expertise of clinicians, managers and researchers to generate consensus on future research priorities in pre-hospital care. The need to develop meaningful performance measures plus alternative methods of patient management illustrates the synergistic relationship between service delivery and performance measurement. It suggests an opportunity to identify alternatives to response times as indicators of quality of pre-hospital care. The final results from this study will be useful to commissioners when developing their strategic approach to decision making about which research should be funded to facilitate continued development of quality patient care in the pre-hospital setting.

BACKGROUND:To identify the benefits of a network in emergency and unscheduled care research, a six week scoping study was undertaken. Objectives were to: draw together stakeholders; identify and prioritise research topics; identify sites for recruitment to studies; and agree a research strategy for a network.METHODS:A workshop was held to discuss and agree a research strategy based on results from four activities: visits to established research centres in emergency and unscheduled care; a literature overview; interviews with stakeholders in a GP out-of-hours service; and an exploration of the potential for routine data to support research in emergency care.RESULTS:Participants attended the workshop from user groups, primary care, the ambulance service, social care, the national telephone based health helpline, the Welsh Assembly Government and the academic sector. Site visits identified opportunities for collaboration. Gaps in knowledge were identified concerning the effectiveness of alternative models of emergency care delivery. Interview data highlighted a lack of evidence related to the quality of out-of-hours provision of primary care. The All Wales Injury Surveillance System (AWISS) was found to offer the potential to use routine data to support quantitative studies in emergency care. Three key issues emerged across all activities: working across boundaries; patient involvement; and triage.CONCLUSION:The study included views from patient, provider, policy and academic perspectives and built the case for a research network in emergency care. Now funded, TRUST (Thematic Research network for emergency and UnScheduled Treatment) will allow the development of research proposals, building of research teams and recruitment of sites and patients both in Wales and across the UK. It aims to address the imbalance between investment and research in this area and help support provision of 'the right care to the right people at the right time'.