I am Professor of Healthcare Workforce Organisation and Wellbeing in the School of Health Sciences at the University of Surrey. I have worked in Health Services Research since 1997, following completion of a Psychology degree at Swansea University. My academic career began at Imperial College London (1997-2002) followed by Kings College London (2002-2017).
My main research interests are improving the wellbeing of the NHS workforce and assessing and improving multidisciplinary team working in healthcare teams. In relation to the wellbeing of NHS staff, I have conducted national cohort studies of mental health in hospital consultants, and worked alongside Professor Jill Maben (also at University of Surrey) to complete a national evaluation of Schwartz Center Rounds in the UK, funded by the NIHR. I am currently funded by NIHR to complete a realist synthesis aimed at understanding how to improve mental wellbeing in nurses, midwives and paramedics. My work in relation to multidisciplinary teams led to the development of a cancer multidisciplinary team assessment and feedback tool (named MDT-FIT) that won QiC Oncology Digital Innovation of the Year in 2016. I am currently working with Surrey and Sussex Cancer Alliance to support and evaluate improvements to multidisciplinary team meetings across three tumour pathways.
My main research interests are improving the wellbeing of the NHS workforce, and assessing and improving multidisciplinary teamwork in healthcare (particularly where two or more specialisms are required to come together e.g. for multimorbidity).
Indicators of esteem
London Research for Patient Benefit (RfPB) Funding Committee member: January 2016 - September 2020
Schwartz Center Rounds (?Rounds?) are a multidisciplinary forum in which healthcare staff within an organisation discuss the psychological, emotional and social challenges associated with their work in a confidential and safe environment. Implemented in over 375 North American organisations, since 2009, they have been increasingly adopted in England. This study aimed to establish how many and what types of organisations have adopted Rounds in England, and to explore why they did so.Setting:
Public healthcare organisations in England. Participants: Secondary data analysis was used to map and profile all 116 public healthcare organisations that had adopted Rounds in England by July 2015. Semistructured telephone interviews were conducted with 45 Round coordinators within adopting organisations.Results:
The rate of adoption increased after a major national report in 2013. Rounds were typically adopted in order to improve staff well-being. Adopting organisations scored better on staff engagement than non-adopters; among adopting organisations, those performing better on patient experience were more likely to adopt earlier. Most adoption decision-making processes were straightforward. A confluence of factors?a generally favourable set of innovation attributes (including low cost), advocacy from opinion leaders in different professional networks, active dissemination by change agents and a felt need to be seen to be addressing staff well-being?initially led to Rounds being seen as ?an idea whose time had come?. More recent adoption patterns have been shaped by the timing of charitable and other agency funding in specific geographical areas and sectors, as well as several forms of ?mimetic pressure?.Conclusions:
The innate attributes of Rounds, favourable circumstances and the cumulative impact of a sequence of distinct informal and formal social processes have shaped the pattern of their adoption in England.
Lymphedema is a common consequence of breast cancer treatment requiring life-long treatment to reduce symptoms and prevent complications. Evidence to inform the optimal decongestive lymphedema treatment package is lacking.Objective
To identify the effect of decongestive lymphedema treatment on excess arm volume or patient-centered outcomes for women presenting within either 12 months or mean 9 months of developing arm lymphedema following breast cancer treatment.Inclusion criteria
Types of participants: women who received lymphedema treatment within either 12 months or mean 9 months of developing unilateral breast cancer-related arm lymphedema. Types of intervention: any decongestive lymphedema treatment delivered with the purpose of reducing arm lymphedema, compared to another form of lymphedema treatment (whether self or practitioner administered), placebo or no treatment. Types of outcomes: clinical outcome was excess arm volume; patient-centered outcomes were health related quality of life, arm heaviness, arm function, patient-perceived benefit and satisfaction with treatment. Types of studies: experimental study designs were eligible, including randomized and non-randomized controlled trials, quasi-experimental, prospective and retrospective before and after studies.Search strategy
A three-step search strategy was utilized to find published and unpublished studies. The search identified studies published from inception of each database to 6th July 2016. Reference lists were scanned to identify further eligible studies.Methodological quality
Studies were critically appraised using appropriate standardized critical appraisal instruments from The Joanna Briggs Institute.Data extraction
Details describing each study and treatment results regarding outcomes of interest were extracted from papers included in the review using appropriate standardized data extraction tools from The Joanna Briggs Institute.Data synthesis
Due to heterogeneity in included studies, results for similar outcome measures were not pooled in statistical meta-analysis. A narrative and tabular format was used to synthesize results from identified and included studies.Results
Seven studies reporting results for outcomes of interest were critically appraised and included in the review: five randomized controlled trials and two descriptive (uncontrolled) studies. Reported outcomes included excess arm volume (five studies), health-related quality of life (three studies), arm heaviness (one study), arm function (two studies) and patient-perceived benefit (two studies). There was some evidence that decongestive treatments were effective for women presenting within either 12 months or mean 9 months of developing breast cancer-related arm lymphedema, but the wide range of data prevented comparison of treatment findings which limited our ability to answer the review questions.Conclusions
Weak evidence (grade B) for the impact of decongestive lymphedema treatment on women with early lymphedema (i.e. less than 12 months duration of BCRL symptoms) did not allow any conclusions to be drawn about the most effective treatment to be offered when these women first present for treatment. Findings provided no justification to support change to current practice. Future primary research needs to focus on the most effective treatment for women when they first present with lymphedema symptoms, e.g. treatment provided within 12 months of developing symptoms. Studies should be adequately powered and recruit women exclusively with less than 12 months duration of BCRL symptoms, provide longer follow-up to monitor treatment effect over time, with comparable treatment protocols, outcome measures and reporting methods.
Cardiac disease is associated with adverse outcomes in pregnancy and is the leading cause of indirect maternal death in the United Kingdom (UK) and internationally. National and international guidelines recommend women should receive care from multidisciplinary teams; however evidence is lacking to inform how they should be operationalised.
To describe the composition and processes of multidisciplinary care between maternity and cardiac services before, during and after pregnancy for women with cardiac disease, and explore clinicians? (cardiologists, obstetricians, nurses, midwives) and women?s experiences of delivering/receiving care within these models.
Mixed-methods comprising case-note audit, interviews and observation.
Two inner-city National Health Service (NHS) maternity units in the south of England serving similar obstetric populations, selected to represent different models of multidisciplinary team care.
Women with significant cardiac disease (either arrhythmic or structural, e.g. tetralogy of fallot) who gave birth between June 1/st 2014 and 31/st May 2015 (audit/interviews), or attended an multidisciplinary team clinic (obstetric/cardiac) during April 2016 (observation).
A two-phase sequential explanatory design was undertaken. A retrospective case-note audit of maternity and medical records (n/=/42 women) followed by interviews with a sub-sample (n/=/7 women). Interviews were conducted with clinicians (n/=/7) and observation of a multidisciplinary team clinic in one site (n/=/8 women, n/=/4 clinicians).
The interests and expertise of individual clinicians employed by the hospital trusts influenced the degree of integration between cardiac and maternity care. Integration between cardiac and maternity services varied from an ad-hoc ?collaborative? model at Site B to an ?interdisciplinary? approach at Site A. In both sites there was limited documented evidence of individualised postnatal care plans in line with national guidance. Unlike pathways for risk assessment, referral and joined care in pregnancy for women with congenital cardiac disease, pathways for women with acquired conditions lacked clarity. Midwives at both sites were often responsible for performing the initial maternal cardiac risk assessment despite minimal training in this. Clinicians and women?s perceptions of ?normality? in pregnancy/birth, and its relationship to ?safe? maternity care were at odds.
The limited evidence and guidance to support multidisciplinary team working for pregnancy in women with cardiac disease ? particularly those with acquired conditions ? has resulted in variable models and pathways of care. Evidence-based guidance regarding the operationalisation of integrated care between maternity and cardiac services ? including pathways between local and specialist centres ? for all women with cardiac disease in pregnancy is urgently required.
To estimate prevalence and explore potential causes and consequences of compassion satisfaction and compassion fatigue in UK emergency medicine consultants.Methods
A sequential mixed-methods design. Cross-sectional e-survey to all UK NHS emergency medicine consultants (n=1317) including Professional Quality of Life (ProQOL) (compassion satisfaction/fatigue), followed by interviews with consultants scoring above (n=6) and below (n=6) predefined ProQOL thresholds.Results
681 (52%) consultants responded. Most (98%) reported at least ?average? compassion satisfaction. Higher scores were associated with type of workplace (designated trauma centres faring better) and number of years worked as a consultant (gradually worsen over time, except 20?years onwards when it improves). Consultants with lower (worse) compassion satisfaction scores were more likely to report being irritable with patients or colleagues and reducing their standards of care (a third reported these behaviours at least monthly) and were more likely to intend to retire early (59% had such plans). Key features distinguishing ?satisfied? from ?fatigued? interviewed consultants included having strategies to deal with the high work intensities associated with their role and having positive views of the team within which they worked. The degree of variety in their roles and the ability to maintain empathy for their patients were also distinguishing features between these groups.Conclusions
Findings support an urgent review of workforce and resources in emergency medicine and suggest that a multifactorial approach to identification, prevention and treatment of occupational stress in the workforce is required that considers individual, job and organisational factors, particularly those that impact on perceived control and support at work.
Despite numerous publications stating the importance of multidisciplinary care for women with pre-existing medical conditions, there is a lack of evidence regarding structure or processes of multidisciplinary working, nor impact on maternal or infant outcomes. This study aimed to evaluate the implementation of guidelines for multidisciplinary team (MDT) management in pregnant women with pre-existing diabetes or cardiac conditions. These conditions were selected as exemplars of increasingly common medical conditions in pregnancy for which MDT management is recommended to prevent or reduce adverse maternal and fetal outcomes.
National on-line survey sent to clinicians responsible for management or referral of women with pre-existing diabetes or cardiac conditions in UK National Health Service (NHS) maternity units. The survey comprised questions regarding the organisation of MDT management for women with pre-existing diabetes or cardiac conditions. Content was informed by national guidance.
One hundred seventy-nine responses were received, covering all health regions in England (162 responses) and 17 responses from Scotland, Wales and Northern Ireland. 132 (74%) related to women with diabetes and 123 (69%) to women with cardiac conditions. MDT referral was reportedly standard practice in most hospitals, particularly for women with pre-existing diabetes (88% of responses vs. 63% for cardiac) but there was wide variation in relation to MDT membership, timing of referral and working practices. These inconsistencies were evident within and between maternity units across the UK. Reported membership was medically dominated and often in the absence of midwifery/nursing and other allied health professionals. Less than half of MDTs for women with diabetes met the recommendations for membership in national guidance, and although two thirds of MDTs for women with cardiac disease met the core recommendations for membership, most did not report having the extended members: midwives, neonatologists or intensivists.
The wide diversity of organisational management for women with pre-existing diabetes or cardiac conditions is of concern and merits more detailed inquiry. Evidence is also required to support and better define the recommendations for MDT care.
(i) To synthesise the evidence-base for Schwartz Center Rounds® (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds.Design:
Systematic review of Rounds literature; scoping reviews of comparator interventions (Action Learning Sets; After Action Reviews; Balint Groups; Caregiver Support Programme; Clinical Supervision; Critical Incident Stress Debriefing; Mindfulness-Based Stress Reduction; Peer Supported Storytelling; Psychosocial Intervention Training; Reflective Practice Groups; Resilience Training).Data Sources:
PsychINFO, CINAHL, MEDLINE, and EMBASE, internet search engines; consultation with experts.Eligibility criteria:
Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English.Results:
The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (ten studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients, and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders : Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace wellbeing as arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the wellbeing of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff wellbeing.
Cancer is diagnosed and managed by multidisciplinary teams (MDTs) in the UK and worldwide, these meet regularly in multidisciplinary team meetings (MDMs) to discuss individual patient treatment options. Rising cancer incidence and increasing case complexity has increased pressure on MDMs. Streamlining discussions has been suggested as a way to enhance efficiency and ensure high quality discussion of complex cases.
Secondary analysis of quantitative and qualitative data from a national survey of 1,220 MDT members regarding their views about streamlining MDM discussions.
The majority of participants agreed that streamlining discussions may be beneficial although variable interpretations of ?streamlining? were apparent. Agreement levels varied significantly by tumour type and occupational group. The main reason for opposing streamlining were concerns about the possible impact on the quality and safety of patient care. Participants suggested a range of alternative approaches for improving efficiency in MDMs in addition to the use of treatment protocols and pre-MDT meetings.
This work complements previous analyses in supporting the development of tumour specific guidance for streamlining MDM discussions considering a range of approaches. The information provided about the variation in opinions between MDT for different tumour types will inform the development of these guidelines. The evidence for variation in opinions between those in different occupational groups and the reasons underlying these opinions will facilitate their implementation. The impact of any changes in MDM practices on the quality and safety of patient care requires evaluation.
Schwartz Center Rounds® (henceforce Rounds) were developed in the United States (US) in 1995 to provide a regular, structured time and safe place for staff to meet to share the emotional, psychological and social challenges of working in healthcare. Rounds were adopted in the United Kingdom (UK) in 2009 and have been subsequently implemented in over 180 healthcare organisations. Using Rounds as a case study, we aim to inform current debates around maintaining fidelity when an intervention developed in one country is transferred and implemented in another.
Interpretive design using nine qualitative interviews (UK = 3, US = 6) and four focus groups (UK: Focus group 1 (4 participants), Focus group 2 (5 participants; US: focus group 1 (5 participants) focus group 2 (2 participants) with participants involved in Rounds design and implementation, for example, programme architects, senior leaders, mentors and trainers. We also conducted non-participant observations of Rounds (UK = 42: USA = 2) and training days (UK = 2). Data were analysed using thematic analysis.
We identified four core and seven sub-core Rounds components, based upon the US design, and seven peripheral components, based on our US and UK fieldwork. We found high core component fidelity and examples of UK adaptations. We identified six strategies used to maintain high fidelity during Rounds transfer and implementation from the US to UK settings: i) having a legal contract between the two national bodies overseeing implementation, ii) requiring adopting UK healthcare organisations to sign a contract with the national body, iii) piloting the intervention in the UK context, iv) emphasising the credibility of the intervention, v) promoting and evaluating Rounds, and vi) providing implementation support and infrastructure.
This study identifies how fidelity to the core components of a particular intervention was maintained during transfer from one country to another by identifying six strategies which participants argued had enhanced fidelity during transfer of Rounds to a different country, with contractual agreements and legitimacy of intervention sources key. Potential disadvantages include limitations to further innovation and adaptation.
Background: Increasing numbers of UK women have overweight or obese BMIs when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise, and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.
Objectives: To assess feasibility of conducting a definitive RCT to determine effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal setting and motivation to achieve dietary change commencing 8 to 16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviours.
Design: A randomised two arm feasibility trial, with a nested mixed-methods process evaluation.
Setting: A single centre in an inner city setting in the south of England
Participants: Women with BMIs>25kg/m2 at antenatal booking and women with normal BMIs (18.5kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks gestation.
Feasibility objectives: Recruitment, retention, acceptability of study processes and identification of relevant economic data. The proposed primary outcome was difference between groups in weight 12 months postnatally, expressed as % weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol, body image, maternal esteem, mental health, infant feeding and NHS costs.
Results: Most objectives were achieved. 193 women were recruited, 98 allocated to the intervention and 95 to the control. High follow up rates (>80%) were achieved to 12 months. A possible 8.8% benefit in weight change at 12 months compared with booking BMI was found among intervention women, compared with control (4.2% compared to 13.0% p=0.062) , 47% of whom attended at least one weight management session, with low risk of contamination between groups. Greatest benefit was among women who attended 10+ sessions. Barriers to attending sessions included opportunity, capability and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.
Limitations: The study only recruited from one site. It was not possible to recruit women with normal BMIs who developed excessive pregnancy weight gain.
Conclusion: It was feasible to recruit and retain women with overweight or obese BMIs at pregnancy commencement to a trial of postnatal weight management plus standard care compared to standard care only, and collect relevant data to assess outcomes. Approaches to recruit women with normal BMIs who gain excessive gestational weight need to be considered. Commercial weight management groups could support women?s weight management as assessed at 12 months postnatally, with likely greater benefit from attending 10+ sessions. Process evaluation findings highlighted importance of providing more information about the intervention on study allocation, extended duration of time to commence sessions following birth, and extended number of sessions offered to enhance uptake and retention.
Future work: Results support the conduct of a future effectiveness RCT.
A high BMI during and after pregnancy is linked to poor pregnancy outcomes and contributes to long-term maternal obesity, hypertension, and diabetes. Evidence of feasible, effective postnatal interventions is lacking. This randomised controlled trial will assess the feasibility of conducting a future definitive trial to determine effectiveness and cost-effectiveness of lifestyle information and access to Slimming World® (Alfreton, UK) groups for 12 weeks commencing from 8 to 16 weeks postnatally, in relation to supporting longer-term postnatal weight management in women in an ethnically diverse inner city population.
Women will be recruited from one maternity unit in London. To be eligible, women will be overweight (BMI 25?29.9 kg/m2) or obese (BMI e 30 kg/m2) as identified at their first antenatal contact, or have a normal BMI (18.5?24.9 kg/m2) at booking but gain excessive gestational weight as assessed at 36 weeks gestation. Women will be aged 18 and over, can speak and read English, expecting a single baby, and will not have accessed weight management groups in this pregnancy. Women will be randomly allocated to standard care plus lifestyle information and access to Slimming World® (Alfreton, UK) groups or standard care only. A sample of 130 women is required.
Feasibility trial objectives reflect those considered most important inform a decision about undertaking a definitive future trial. These include estimation of impact of lifestyle information and postnatal access to Slimming World® (Alfreton, UK) on maternal weight change between antenatal booking weight and weight at 12 months postbirth, recruitment rate and time to recruitment, retention rate, influence of lifestyle information and Slimming World® (Alfreton, UK) groups on weight management, diet, physical activity, breastfeeding, smoking cessation, alcohol intake, physical and mental health, infant health, and health-related quality of life 6 and 12 months postnatally. An embedded process evaluation will assess acceptability of study processes and procedures to women.
London?Camberwell St Giles Research Ethics Committee, reference: 16/LO/1422. Outcomes will be disseminated in peer-reviewed journals and presentations at national and international conferences.
Trial registration number: ISRCTN 39186148. Protocol version number: v7, 13 August 17. Trial sponsor: King?s College London.
To assess feasibility of a future randomised controlled trial (RCT) of clinical and cost?effectiveness of lifestyle information and commercial weight management groups to support postnatal weight management to 12 months post?birth.
Two?arm feasibility trial, with nested mixed?methods process evaluation.
Inner?city unit, south England.
Women with body mass indices (BMIs) e25 kg/m2 at pregnancy booking or normal BMIs (18.5?24.9 kg/m2) identified with excessive gestational weight gain at 36 weeks of gestation.
Randomised to standard care plus commercial weight management sessions commencing 8?16 weeks postnatally or standard care only.
Feasibility outcomes included assessment of recruitment, retention, acceptability and economic data collation. Primary and secondary end points included difference between groups in weight 12 months postnatally compared with booking (proposed primary outcome for a future trial), diet, physical activity, smoking, alcohol, mental health, infant feeding, NHS resource use.
In all, 193 women were randomised: 98 intervention and 95 control; only four women had excessive gestational weight gain. A slightly greater weight change was found among intervention women at 12 months, with greatest benefit. Among women attending ten or more weight management sessions. There was >80% follow up to 12 months, low risk of contamination and no group differences in trial completion.
It was feasible to recruit and retain women with BMIs e25 kg/m2 to an intervention to support postnatal weight management; identification of excessive gestational weight gain requires consideration. Economic modelling could inform out?of?trial costs and benefits in a future trial. A definitive trial is an important next step.
A feasibility RCT of postnatal weight support showed women with BMIs e25 kg/m2 can be recruited and followed to 12 months postnatally.
Early initiation of breastfeeding and exclusive breastfeeding can reduce infant mortality. Breastfeeding support interventions such as counselling may improve adherence to recommended practices. However, it is not known if these interventions work at the population level.
The aim of this study was to assess the relationship between early postnatal breastfeeding support and recommended breastfeeding practices.
We pooled data from 11 Demographic and Health Surveys in Africa (n = 7), South East Asia (n = 2), the Americas (n = 1), and Europe (n = 1) to analyse these associations at the population level.
We limited the data to the most recent live births in the two years before the survey, including 41,431 births.
We fitted three multivariable logistic regression models to estimate the relationship between early postnatal breastfeeding support (a newborn postnatal check within an hour of birth plus counselling and observation of breastfeeding within two days) and three breastfeeding outcomes (early initiation of breastfeeding, absence of prelacteal feeding, and exclusive breastfeeding), adjusting for sociodemographic characteristics and birth-related factors.
Early breastfeeding support was associated with a 24% increase (OR=1.24 95%CI=1.11,1.39) in the odds of initiating breastfeeding within one hour of birth. No relationships were found between breastfeeding support and prelacteal feeding in the first three days or exclusive breastfeeding at six months.
While postnatal breastfeeding counselling and observation may improve early initiation of breastfeeding, impact is not persistent for longer term breastfeeding outcomes.
Implication for practice:
Improved training for breastfeeding support and an enabling policy environment are required to improve breastfeeding practices for women and newborns.
Despite a reduction in overall maternal mortality in the United Kingdom (UK) during recent decades, maternal mortality rates over the previous six years have started to increase (Knight et al. 2019), and maternal deaths associated with pre-existing physical and/or psychological comorbidities are increasing nationally and globally (Nair et al. 2017). Surveillance data from the UK and Ireland suggests that most women who died during or following pregnancy in the period 2015 to 2017 had multiple health problems and/or additional complex social factors (Knight et al. 2019). This is mirrored in maternal mortality case reviews in other high-income countries including United States of America (USA) (Creanga et al. 2015), Australia (Australian Institute of Health and Welfare 2017) and New Zealand (Perinatal and Maternal Mortality Review Committee 2018).
Whilst maternal mortality rates in other high-income countries have also decreased over the past two decades, ranging from 3 to 12 deaths per 100,000 live births (WHO 2018a), severe maternal morbidity rates are increasing (Gellar et al. 2018), as a consequence of pre-existing and pregnancy related health problems, often reflecting multiple complex health and social needs. In the USA for example, overall severe maternal morbidity rates increased from 74 per 10,000 hospital births in 1998?99 to 163 in 2010?11 (Creanga et al. 2014). In the UK and Ireland more than two-thirds (68%) of the women who died during or after pregnancy in the triennial period 2014-2016 were known to have pre-existing medical problems (Knight et al. 2018). Conditions associated with increased maternal morbidity include obesity (Dudenhausen 2015, NHSE 2018a) diabetes (Coton et al. 2016, Feig et al. 2018) cardiac disease (Roos-Hesselink 2019) and severe mental illness (Estrin et al. 2019, Xu et al. 2014). Increasing numbers of women have physical and/or psychological comorbidities prior to becoming pregnant (Molyneaux et al. 2014, Ruhstaller et al. 2017, Kumpulainen 2018). These women are at greater risk of adverse pregnancy outcomes than women in the general pregnant population (Mhyre et al. 2011, Nair et al. 2015) and it is imperative that maternity policy acknowledges and addresses the impact of the changing health-profile of women to consider how to prevent or at least reduce maternal morbidity.
Multi-disciplinary meetings (MDMs) have been the gold standard of cancer care in the UK since the 1990s. Our aim was to identify the views of UK Urology cancer multi-disciplinary team (MDT) members on ways to improve the functioning of MDMs and compare them with other specialities in order to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases.
Materials and Methods
An analysis of data from two national surveys (2294 and 1258 MDT members respectively) distributed by Cancer Research UK, focussing on their views about cancer MDT meetings.
The majority of Breast, Colorectal, Lung and Urology cancer teams felt that cancer MDMs could be improved in the following areas: time for MDM preparation in job plans, streamlining of patients, auditing MDT decisions and prioritising complex cases. With regards streamlining, 87% percent of Urology respondents agreed some patients could be managed outside a full MDT discussion. The support was lower in other specialities (Breast 75%, Colorectal 64%, Lung 78%).
To facilitate decisions on which patients do require discussion, factors across all tumour types were identified as adding to case complexity, including rare tumour type, cognitive impairment and previous treatment failure.
This study confirms that Urology MDT members are supportive of a change in approach from reviewing all new cancer diagnoses to discussing complex cases with all others managed using a more protocolised pathway. The mechanism for how this is done and how the safety of patients is ensured requires further clarification.
Increasing numbers of UK women have overweight or obese body mass index scores when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.
The objectives were to assess the feasibility of conducting a definitive randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal-setting and motivation to achieve dietary change commencing 8?16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviour.
The design was a randomised two-arm feasibility trial with a nested mixed-methods process evaluation.
The setting was a single centre in an inner city setting in the south of England.
Participants were women with body mass index scores of Ã 25 kg/m2 at antenatal ?booking? and women with normal body mass index scores (18.0?24.9 kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks? gestation.
Main outcome measures
Recruitment, retention, acceptability of trial processes and identification of relevant economic data were the feasibility objectives. The proposed primary outcome was difference between groups in weight at 12 months postnatally, expressed as percentage weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol consumption, body image, maternal esteem, mental health, infant feeding and NHS costs.
Most objectives were achieved. A total of 193 women were recruited, 98 allocated to the intervention arm and 95 to the control arm. High follow-up rates (Ã 80%) were achieved to 12 months. There was an 8.8% difference in weight loss at 12 months between women allocated to the intervention arm and women allocated to the control arm (13.0% vs. 4.2%, respectively; p = 0.062); 47% of women in the intervention arm attended at least one weight management session, with low risk of contamination between arms. The greatest benefit was among women who attended e 10 sessions. Barriers to attending sessions included capability, opportunity and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.
The trial recruited from only one site. It was not possible to recruit women with normal body mass index scores who developed excessive pregnancy weight gain.
It was feasible to recruit and retain women with overweight or obese body mass index scores at antenatal booking to a trial comparing postnatal weight management plus standard care with standard care only and collect relevant data to assess outcomes. Approaches to recruit women with normal body mass index scores who gain excessive gestational weight need to be considered. Commercial weight management groups could support women?s weight management as assessed at 12 months postnatally, with probable greater benefit from attending e 10 sessions. Process evaluation findings highlighted the importance of providing more information about the intervention on trial allocation, extended duration of time to commence sessions following birth and extended number of sessions offered to enhance uptake and retention. Results support the conduct of a future randomised c