Papers by Joanne Turnbull
eHealth literacy and the use of NHS111 online urgent care service in England: A cross-sectional survey (Preprint)
JMIR. Journal of medical internet research/Journal of medical internet research, Jun 28, 2023
Objective To determine the impact of transanastomotic tube (TAT) feeding in congenital duodenal o... more Objective To determine the impact of transanastomotic tube (TAT) feeding in congenital duodenal obstruction (CDO). Design Systematic review with meta-analysis. Patients Infants with CDO requiring surgical repair. Interventions TAT feeding following CDO repair versus no TAT feeding. The main outcome was time to full enteral feeds. Additional outcomes included use of parenteral nutrition (PN), cost and complications from either TAT or central venous catheter. Meta-analyses were undertaken using random-effects models (mean difference (MD) and risk difference (RD)), and risk of bias was assessed using the Risk Of Bias In Non-randomised Studies -of Interventions (ROBINS-I) tool. Results Twelve out of 373 articles screened met the inclusion criteria. All studies were observational and two were prospective. Nine studies, containing 469 infants, were available for meta-analysis; however, four were excluded due to serious or critical risk of bias. TAT feeding was associated with reduced time to full enteral feeds (-3.34; 95% CI -4.48 to -2.20 days), reduced duration of PN (-6.32; 95% CI -7.93 to -4.71 days) and reduction in nutrition cost of £867.36 (95% CI £304.72 to £1430.00). Other outcomes were similar between those with and without a TAT including inpatient length of stay (MD -0.97 (-5.03 to 3.09) days), mortality (RD -0.01 (-0.04 to 0.01)) and requirement for repeat surgery (RD 0.01 (-0.03 to 0.05)). Conclusion TAT feeding following CDO repair appears beneficial, without increased risk of adverse events; however, certainty of available evidence is low. Earlier enteral feeding and reduced PN use are known to decrease central venous catheter-associated risks while significantly reducing cost of care. PROSPERO registration number CRD42022328381. ⇒ Further understanding of barriers to use of transanastomotic tubes is required in order to promote use and improve outcomes in infants with congenital duodenal obstruction. copyright.
Emergency and On-Demand Healthcare: Modeling a Large Complex System
This paper describes how system dynamics was used as a central part of a whole-system review of e... more This paper describes how system dynamics was used as a central part of a whole-system review of emergency and on-demand healthcare in Nottingham, England. Based on interviews with 30 key individuals across health and social care, a ‘conceptual map’ of the system was developed, showing potential patient pathways through the system. This was used to construct a stock-flow model, populated with current activity data, in order to simulate patient flows and to identify system bottle-necks. Without intervention, assuming current trends continue, Nottingham hospitals are unlikely to reach elective admission targets or achieve the government target of 82% bed occupancy. Admissions from general practice had the greatest influence on occupancy rates. Preventing a small number of emergency admissions in elderly patients showed a substantial effect, reducing bed occupancy by 1% per annum over 5 years. Modelling indicated a range of undesirable outcomes associated with continued growth in demand for emergency care, but also considerable potential to intervene to alleviate these problems, in particular by increasing the care options available in the community.
(2000) Cost analysis of nurse telephone consultation in out-of-hours primary care: evidence from ... more (2000) Cost analysis of nurse telephone consultation in out-of-hours primary care: evidence from a randomised controlled trial. BMJ, 320 (7241). pp. 1053-1057.
BMJ, Oct 17, 1998
Objective To determine the safety and effectiveness of nurse telephone consultation in out of hou... more Objective To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls. Design Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention. Setting One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire. Subjects All patients contacting the out of hours service or about whom contact was made during specified times over the trial year. Intervention A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 6 15 pm to 11 15 pm from Monday to Friday, 11 00 am to 11 15 pm on Saturday, and 8 00 am to 11 15 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support software. Main outcome measures Deaths within seven days of a contact with the out of hours service; emergency hospital admissions within 24 hours and within three days of contact; attendance at accident and emergency within three days of a contact; number and management of calls in each arm of the trial. Results 14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments. Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective.
Diabetes Research and Clinical Practice, Aug 1, 2001
We have investigated the incidence of newly diagnosed Type 2 diabetes in the Poole area and extra... more We have investigated the incidence of newly diagnosed Type 2 diabetes in the Poole area and extrapolated it to the rest of the UK. Methods: this prospective observational study used a surveillance programme in primary and secondary care. We identified all cases of newly diagnosed Type 2 diabetes mellitus occurring from 1st May 1996 to 30th June 1998 through the normal health care process without any active screening in 186 889 people registered with 24 primary care practices in the Poole area. Results: the 1996 prevalence of diagnosed Type 2 diabetes in this population was 1.59 (95% CI 1.53-1.65%)%. During the first 24 months of the study, 706 new cases of Type 2 diabetes mellitus, 382 men and 324 women, were identified. The crude annual incidence of newly diagnosed Type 2 diabetes, thus was 1.93/1000 (95% CI 1.73-2.13%) and age/sex adjusted incidence was 1.67/1000 (95% CI 1.49-1.84%). The age-adjusted incidence was higher in men, 1.86/1000 (95% CI 1.60-2.13), than in women, 1.48/1000 (95% CI 1.25-1.71%), relative risk 1.26 (95% CI 0.997-1.527%), but this difference did not reach statistical significance. Mean HbA 1c at diagnosis was 10.8 (S.D. 2.9%)%. Men were younger at diagnosis than women (mean age, 62.9 vs. 65.9%, PB0.01). Conclusion: in UK, prior to the change in the WHO diagnostic criteria for diabetes, we estimate that over 98 000 new cases of Type 2 diabetes were diagnosed each year.
A simulation study to improve time to first chest compression and depth of compression following an enhanced T-CPR protocol in Saudi Arabia
Resuscitation, Oct 1, 2020
Emergency Medicine Journal, Nov 1, 2004
To investigate patients' strength of preferences for attributes associated with modernising deliv... more To investigate patients' strength of preferences for attributes associated with modernising delivery of out of hours emergency care services in Nottingham. Methods: A discrete choice experiment was applied to quantify preferences for key attributes of out of hours emergency care. The attributes reflected the findings of previous research, current policy initiatives, and discussions with local key stakeholders. A self complete questionnaire was administered to NHS Direct callers and adults attending accident and emergency, GP services and NHS walk-in centre. Regression analysis was used to estimate the relative importance of the different attributes. Results: Response was 74% (n = 457) although 61% (n = 378) were useable. All attributes were statistically significant. Being consulted by a doctor was the most important attribute. This was followed by being consulted by a nurse, being kept informed about waiting time, and quality of the consultation. Respondents were prepared to wait an extra 2 hours 20 minutes to be consulted by a doctor. There were no measurable preference differences between patients surveyed at different NHS entry points. Younger respondents preferred single telephone call access to health care out of hours. Although having services provided close to home and making contact in person were generally preferred, they were less important than others, suggesting that a range of service locations may be acceptable to patients. Conclusions: This study showed that local solutions for reforming emergency out of hours care should take account of the strength of patient preferences. The method was acceptable and the results have directly informed the development of a local service framework for emergency care.
Making sense of urgent care: how and why do people use health services?
Urgent care typically describes healthcare for non-life threatening conditions requiring prompt a... more Urgent care typically describes healthcare for non-life threatening conditions requiring prompt attention (‘same day’ or within 24 hours). In England, urgent care services have proliferated partly to divert people from attending overcrowded emergency departments but also to address policy concerns of patient choice and improved access to care. This wider choice of services has led to a complex landscape of urgent and emergency care where boundaries between different services are blurred. Service users are often confused about which service to use. This includes using emergency care for ‘non-emergency’ health problems. Research around this topic has often focused on the ‘inappropriate’ use of emergency services. However, categorisations of ‘appropriate’ or ‘inappropriate’ behaviours are simplistic. This Evidence Brief describes the findings of a two-year study undertaken by the University of Southampton and NHS collaborators at University Hospitals Southampton and South Central Ambulance Service. This research examined the amount and nature of effort (‘work’) service users undertake to make sense of urgent care and seek help from health services. <br/
Out-of-hours general practice : an investigation of patients' use and experiences of access to services
EThOS - Electronic Theses Online ServiceGBUnited Kingdo
Does distance matter? Geographical variation in the use of general practice out-of-hours services
The Exemplar Programme for integrated out-of-hours care: evaluation report
Lattimer, Val, Gerard, Karen, George, Steve, Smith, Helen, Lathlean, Judith, Burgess, Abigail, Tu... more Lattimer, Val, Gerard, Karen, George, Steve, Smith, Helen, Lathlean, Judith, Burgess, Abigail, Turnbull, Joanne and Surridge, Heidi (2004) The Exemplar Programme for integrated out-of-hours care: evaluation report. Southampton, UK, University of Southampton, 276pp.
Health and social care delivery research, Jun 1, 2023
NIHR Journals Library www.journalslibrary.nihr.ac.uk Limitations: This research bridged the pande... more NIHR Journals Library www.journalslibrary.nihr.ac.uk Limitations: This research bridged the pandemic from 2020 to 2021; therefore, findings may change as services adjust going forward. Surveys used a digital platform so there is probably bias towards some level of e-Literacy, but this also means that our data may underestimate the digital divide. Future work: Further investigation of access to digital services could address concerns about digital exclusion. Research comparing the affordances and cost-benefits of different triage and assessment systems for users and health-care providers is needed. Research about trust in virtual assessments may show how duplication can be reduced. Mixed-methods studies looking at outcomes, impacts on work and costs, and ways to measure eHealth literacy, can inform the development NHS 111 online and opportunities for further international shared learning could be pursued. Study registration: This study is registered at the research registry (UIN 5392).
Results: what is the work?
Emergency Medicine Journal, Jul 6, 2023
Background NHS 111 is a phone and online urgent care triage and assessment system that aims to re... more Background NHS 111 is a phone and online urgent care triage and assessment system that aims to reduce UK ED demand. In 2020, 111 First was introduced to triage patients before entry to the ED and to offer direct booking for patients needing ED or urgent care into same-day arrival time slots. 111 First continues to be used post pandemic, but concerns about patient safety, delays or inequities in accessing care have been voiced. This paper examines ED and urgent care centre (UCC) staff experiences of NHS 111 First. Method Semistructured telephone interviews were conducted with ED/UCC practitioners across England between October 2020 and July 2021 as part of a larger multimethod study examining the impact of NHS 111 online. We purposively recruited from areas with high need/ demand likely to be using NHS 111 services. Interviews were transcribed verbatim and coded inductively by the primary researcher. We coded all items to capture experiences of 111 First within the full project coding tree and from this constructed two explanatory themes which were refined by the wider research team. Results We recruited 27 participants (10 nurses, 9 doctors and 8 administrator/managers) working in ED/UCCs serving areas with high deprivation and mixed sociodemographic profiles. Participants reported local triage/streaming systems predating 111 First continued to operate so that, despite prebooked arrival slots at the ED, all attendances were funnelled into a single queue. This was described by participants as a source of frustration for staff and patients. Interviewees perceived remote algorithm-based assessments as less robust than in-person assessments which drew on more nuanced clinical expertise. Discussion While remote preassessment of patients before they present at ED is attractive, existing triage and streaming systems based on acuity, and staff views about the superiority of clinical acumen, are likely to remain barriers to the effective use of 111 First as a demand management strategy. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY ⇒ The continued presence of pragmatic local streaming and preference by staff for face-toface clinical assessment may be a continued barrier to the effective use of 111 First as a demand management strategy for NHS emergency and urgent care.
Help-seeking behaviour, choices, experiences and ‘work’: findings from the qualitative interviews
BMC Health Services Research, Jul 12, 2019
Background: Theoretical models have sought to comprehend and conceptualise how people seek help f... more Background: Theoretical models have sought to comprehend and conceptualise how people seek help from health professionals but it is unclear if such models apply to urgent care. Much previous research does not explain the complex interactions that influence how people make sense of urgent care and how this shapes service use. This paper aims to conceptualise the complexity of sense-making and help-seeking behaviour in peoples' everyday evaluations of when and how to access modern urgent care provision. Methods: This study comprised longitudinal semi-structured interviews undertaken in the South of England. We purposively sampled participants 75+, 18-26 years, and from East/Central Europe (sub-sample of 41 received a second interview at + 6-12 months). Framework analysis was thematic and comparative. Results: The amount and nature of the effort (work) undertaken to make sense of urgent care was an overarching theme of the analysis. We distinguished three distinct types of work: illness work, moral work and navigation work. These take place at an individual level but are also shared or delegated across social networks and shaped by social context and time. We have developed a conceptual model that shows how people make sense of urgent care through work which then influences help-seeking decisions and action. Conclusions: There are important intersections between individual work and their social networks, further shaped by social context and time, to influence help-seeking. Recognising different, hidden or additional work for some groups may help design and configure services to support patient work in understanding and navigating urgent care.
Family Practice, Jun 17, 2005
Background. Governmental reviews of out-of-hours services in England and Scotland have recommende... more Background. Governmental reviews of out-of-hours services in England and Scotland have recommended that a standard questionnaire should be used to assess patient satisfaction. This is important because of the rapid introduction of new forms of care. Objective. To produce a brief, reliable and valid measure of patient satisfaction for use by a wide variety of providers of out-of-hours primary care. Methods. The Short Questionnaire for Out-of-Hours care was designed and compared with a longer questionnaire which had been validated and used in earlier research. Questionnaires were sent to 1906 people contacting an out-of-hours GP co-operative. Three versions of the short questionnaire were used with different formats. Analysis compared the response rates, measurement properties, concurrent and construct validity of the short and long questionnaires, and of different versions of the short questionnaire. There was no significant difference in the overall response rates obtained from the short or long questionnaires (45.7% versus 41.9%; P = 0.17). The effective response rate of questionnaires from which all satisfaction scales could be calculated was higher for the short questionnaire (43.0% versus 36.4%; P = 0.01). There were no significant differences in response rates or distribution of responses between different versions of the short questionnaire. There was moderate agreement between items on the short questionnaire and corresponding scales on the long questionnaire. Scores using the short questionnaire showed anticipated relationships with the age and sex of patients and with characteristics of how the service was delivered. The SQOC is valid and reliable for routine service use.
Health Services and Delivery Research, Jul 1, 2019
Reports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted ... more Reports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. The Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January 2012. The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services. For more information about the HS&DR programme please visit the website:
BMC Medical Research Methodology
Background The failure of randomised controlled trials to adequately reflect areas of highest hea... more Background The failure of randomised controlled trials to adequately reflect areas of highest health need have been repeatedly highlighted. This has implications for the validity and generalisability of findings, for equity and efficiency, but also for research capacity-building. Rai et al. (BMC Med Res Methodol 21:80, 2021) recently argued that the poor alignment between UK clinical research activity (specifically multi-centre RCTs) and local prevalence of disease was, in part, the outcome of behaviour and decision-making by Chief Investigators involved in trial research. They argued that a shift in research culture was needed. Following our recent multi-site mixed methods evaluative study about NHS 111 online we identify some of the additional structural barriers to delivering health research “where populations with the most disease live”, accounting for the Covid-19 disruption to processes and delivery. Methods The NHS 111 study used a mixed-method research design, including inte...
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Papers by Joanne Turnbull