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While social policy falls predominantly under national rather than European Union (EU) jurisdiction, there are nonetheless multiple ways in which social policy and social outcomes in EU member states have been affected by EU membership. This paper draws on existing evidence and analysis to review the consequences for UK social policy of the decision to leave the EU. We focus predominantly on the implications of the British government's pledge to 'take back control' of money, borders and laws. Our conclusion is that Brexit is likely to have negative effects on the quality of public services and, for some groups in particular, social rights, and that these effects are likely to be greater the more distant are the future trading and wider relationships between the UK and the EU27. [ABSTRACT FROM AUTHOR]

A UK doctor was recently acquitted of charges of reinstating a variety of female genital mutilation after delivering a child. In this paper, I contend that this incident reflects a broader confusion concerning the ethico-legal status of non-therapeutic genital surgeries for children and adults, which are not derivable from tenets of medical ethics, but rather violate them. I argue that medical professionals have an obligation to announce and address this confusion in order to motivate legislative reform, since the inconsistency of the current law entrenches the underlying sexism and ethnocentrism upon which its sense depends. Without convincing arguments for (a) condoning male circumcision and female cosmetic genital surgery and for (b) treating adult women of colour as lacking the capacity to consent, the current legislation stands in need of urgent revision. [ABSTRACT FROM AUTHOR]

The criminal law looks set to play a larger role in regulating healthcare. Until recently, health professionals only faced the prospect of criminal liability if it could be proved that their gross negligence resulted in the death of a patient. In such a case, the professional could face a charge of gross negligence manslaughter (GNM). Prosecutions for ‘medical manslaughter’ have generated concern among doctors worried about what is perceived as a rise in the number of doctors facing criminal prosecution and the impact prosecutions are having on healthcare practice. May more frequent resort to the criminal process damage rather than promote better health care? In seeking to try to answer this question, the first problem is that reliable data in this area about how many prosecutions are brought and how they fare are limited due to the way cases are recorded. What evidence does exist is often based on media reports or samples that are not representative. This paper will argue that, while the real risk of being prosecuted for medical manslaughter remains low, such fears should not be dismissed because, as Donald Berwick has argued, ‘fear is toxic’ – for health professionals and their patients. [ABSTRACT FROM AUTHOR]

This paper recognizes the complexity of the debate on informed consent and discusses the importance of the ongoing process of consent for people affected by Huntington's disease (HD). Although written information may not be the most appropriate form of obtaining informed consent in qualitative research, it remains an important part of the ethical approval process for health research in the UK. This paper draws on a study in which the information sheet and consent form were specifically designed to help obtain consent from people who may be impaired by the cognitive and physical effects of HD. The forms were developed by drawing on expert opinion and relevant literature and fall in line with recommendations from the Mental Capacity Act 2005 to encourage people to make their own decisions. The paper describes the feasibility of a method for obtaining consent as an ongoing process with patients affected by HD using information sheets and consent forms specifically designed for people with potential cognitive and/or physical impairments. In conclusion, this paper adds a pragmatic approach to the debate on informed consent by describing the development of a written information sheet and consent form being used in a current social research study. Particular emphasis is placed on the importance of written information being adapted according to the needs of potential participants. [ABSTRACT FROM AUTHOR]

The principle of autonomy is at the heart of the right of a competent individual to make an advance directive that refuses life-sustaining medical treatment, and to have that directive complied with by medical professionals. That right is protected by both the common law and, to an extent, by legislation that has been enacted in the United Kingdom and many jurisdictions in Australia. The courts have a critical role in protecting that autonomy, both in those jurisdictions in which the common law continues to operate and in those jurisdictions which are now governed by statute, and in which judicial determinations will need to be made about legislative provisions. The problem explored in this paper is that while the judiciary espouses the importance of autonomy in its judgments, that rhetoric is frequently not reflected in the decisions that are reached. In the United Kingdom and Australia, there is a relatively small number of decisions that consider the validity and applicability of advance directives that refuse life-sustaining medical treatment. This paper critically evaluates all of the publicly available decisions and concludes that there is cause for concern. In some cases, there has been an unprincipled evolution of common law principles, while in others there has been inappropriate adjudication through operational irregularities or failure to apply correct legal principles. Further, some decisions appear to be based on a strained interpretation of the facts of the case. The apparent reluctance of some members of the judiciary to give effect to advance directives that refuse treatment is also evidenced by the language used in the judgments. While the focus of this paper is on common law decisions, reference will also be made to legislation and the extent to which it has addressed some of the problems identified in this paper. [ABSTRACT FROM AUTHOR]

The article examines the issues surrounding White Paper's uncovering of the proposal to reforming the health professionals' Trust, Assurance and Safety regulation in Great Britain. The White Paper expressed that to reform, the importance of perceptions must be rightly emphasized as public needs to perceive that the regulatory system is operating in the interests of patients. It also stresses that the General Medical Council's (GMC) four functions must be integrated in the regulatory framework.

There are substantial inequities within the current National Health Service (NHS), with people in lower socioeconomic groups (SEGs) using a wide range of services less relative to their needs than people in higher SEGs. These inequities are likely to arise due to factors on both the demand and the supply side of the system. On the demand side, they could arise from differences in patients' beliefs, knowledge, costs, resources and capabilities. On the supply side, professional beliefs and attitudes, and risk selection or cream-skimming by providers may result in inequities. This paper discusses whether these factors are at play within the English NHS and analyses whether current policy to extend patient choice of provider is likely to reduce or increase these inequities. It shows that extending patient choice may leave unchanged inequity due to differences in health beliefs (because choice does not affect these directly), increase inequity due to unequal resources (because patients may have to travel further), and decrease inequity due to unequal capabilities (because the poor will have access to a new and, for them a more effective, source of leverage over health service professionals). On the supply side, there will be little change. The paper then discusses policy options for dealing with factors that contribute to greater inequity on the demand side. It proposes a package of supported choice whereby individuals from lower SEGs would receive assistance in making choices, including an identified key worker to act as patient care adviser and help with transport costs. The paper concludes that policies for extending patient choice can enhance equity – so long as they are properly designed. [ABSTRACT FROM AUTHOR]

This paper examines some fundamental issues pertaining to the use of, as well as to the distinctive characteristics of, information technology in relation to the development of information systems within the UK National Health Service (NHS). The paper refers to the current Resource Management initiative in the NHS, which involves the fabrication of information systems to connect medical activity to resource usage, and thus to costs. Examining the features of some of the rival inscriptions undergoing development of make this connection visible, the paper highlights the properties of information technology in enhancing their mobilization. It also addresses the immutability and combinability of these inscriptions, and discusses some of the implications, in terms of medical practice and knowledge, which may follow from their use. [ABSTRACT FROM AUTHOR]

In the last decade, trauma care has become its own speciality. The creation of major trauma centres across the UK highlighted a clear clinical need to advance services for multiple injury patients who are known to have poor prognostic outcome. The story of trauma care development goes back well before the creation of the National Health Service (NHS). Although originally grouped with emergency medicine, the two have developed into their own distinct branches. This paper highlights key milestones and relationships in the development of trauma medicine alongside emergency medicine, from ancient times to present day, as well as the factors that have made them distinct. Reviewing the past can help medicine move forward. [ABSTRACT FROM AUTHOR]

Recent UK reports have revealed extensive evidence of unethical care practices. Older and vulnerable patients in some British health services have experienced appalling and avoidable suffering. Explanations for, and solutions to, these care failures have been proposed with wide-ranging recommendations. Many of these have direct implications for clinical ethics with additional frameworks for ethical values proposed, a heightened awareness of the moral culture of organisations acknowledged and a renewed interest in the ethics component of professional education debated. In this paper, I suggest that we integrate insights from the slow movement into clinical ethics practice. Distinctions are made between fast and slow healthcare practice and between fast and slow ethics. I argue that, whilst there is a place for both, slow ethics enables us to assume a more positive stance in relation to ‘crisis’, and requires that we learn from past accounts and scholarship and consider the role of clinical ethics in sustaining caring cultures. [ABSTRACT FROM AUTHOR]

NHS research governance makes it almost impossible to collect certain kinds of data on the everyday life of hospitals and the experience of patients. Fortunately, those of us who get sick enough to be admitted can write about the experience without fear of regulation. This paper presents some observations on clinical ethics, ward organization and infection control that would have been difficult to obtain in any other way, but which illustrate the policy and information costs of the present system. While not personally recommending this as a research strategy, the paper identifies a growing evidence gap and comments on its implications for the delivery of humane and well-organized care. [ABSTRACT FROM AUTHOR]

The article presents a paper from John Fry, one of the giants of general practice (GP) in Great Britain, which focused on medical staffing requirements. The paper contained skill mix and work sharing across the primary health care team, the mantra about creating a national service, and independence in organizing general practice services. Additionally, it provides annual summary and figures on total consultations, daily and weekly workload totals for the practice per GP and hospital referrals.

This paper discusses the main ideas of the Diversity Based approach to culturally sensitive practices in health and social care services.This approach is important in emphasizing the fluid nature of culture, the diversity in cultural groups and the impact of inegalitarian and racist power relations on their life. Chinese people in the UK are used as an example to demonstrate how exploration of the diversity of ethnic minority groups could strengthen cultural sensitivity. Some methods for the realization of the Diversity Based approach, such as the culturagram and user involvement, have also been highlighted. [ABSTRACT FROM PUBLISHER]

There is a significant body of evidence showing that patients want to know when they are harmed as a result of their medical care. In 2005 the National Patient Safety Agency issued guidance on the process to be followed when communicating errors to patients and their carers. However, there is still a significant gap between the rhetoric of being open and clinical practice. This gap reflects the competing interests arising from the concept of being open and the difficulties involved in the process itself. This paper presents several case studies to explore the complexities of being open and the organizational support required to overcome these. [ABSTRACT FROM AUTHOR]

The extent to which clinical and public health guidance developed by the National Institute for Health and Clinical Excellence (NICE) can effectively serve the public by improving quality and efficiency across the National Health Service (NHS) and the broader public sector depends largely on the quality and relevance of the available evidence which informs its decisions. There are well-established organizational and procedural links between NICE and academic and professional organizations that undertake evidence synthesis. However, there are fewer means for evidence gaps identified during the development of NICE guidance to lead to the commissioning of new prospective studies. In this paper, we discuss the importance of a publicly funded clinical and public health research agenda that includes new prospective studies aimed at addressing knowledge gaps identified by NICE. We describe the early experience of NICE and the National Institute for Health Research (NIHR) working together to articulate and commission research to inform best practice recommendations. We propose ways in which NICE can collaborate more effectively with research funders to improve the evidence base upon which it bases its recommendations. [ABSTRACT FROM AUTHOR]

Do UK community pharmacists encounter the high drama dilemmas of the medical ethics literature or is a 'morality of the mundane' more appropriate? This paper presents the findings of a qualitative study that asked a sample of UK pharmacists to describe their ethical issues and to establish whether these were ethical dilemmas as understood philosophically or ethical problems of a more legal or emotional nature. It emerged that although many pharmacists referred to 'dilemmas', these were often problems involving a conflict between an ethical value and a legal or procedural issue and often arose in the routine minutiae of dispensing prescriptions and selling medicines. Such ethical problems remained of concern for pharmacists and the commercial environment, corporate pharmacy ownership and pharmacists' subordination to doctors, all precipitated ethical problems. Law and ethics appeared to be understood synonymously but this may reflect a modernity that increasingly brackets out ethical experiences by encouraging reliance upon law and procedure. [ABSTRACT FROM AUTHOR]

Introduction There is an increasing expectation for the NHS to deliver a constantly up-to-date health service that is both safe and patient-oriented. This paper outlines the findings of a new risk assessment tool implemented across the organization targeted specifically to medical devices. Method The process employs a new medical devices risk assessment tool (MeDRa) to collect quantitative data relating to the contributory factors and control measures associated with medical devices used in the clinical setting. The tool utilises the responses from healthcare professionals as the 'real experts' in assessing risk to compute risk ratings for each device. Consequently the risk assessments are validated through the professional judgement of the clinical staff. Results As the data is inputted, the software tool computes the individual risk profiles for device categories in the particular clinical setting. A macro perspective of medical device risk is produced through statistical analysis and mathematical modelling using cross-tabulations. Risk perceptions are influenced by the differences in professional roles of nursing and medical staff. The outcome of the analysis is a report on medical device risks across the organization and an associated action plan, which identifies ways of mitigating those risks. Conclusions This approach efficiently produced risk assessments for each clinical area across the whole Trust in a matter of weeks. The MeDRa tool collated evidence to satisfy many of the criteria necessary for the external assurance framework. The subsequent statistical analysis and mathematical modelling highlighted a number of issues across the Trust that required interventions. [ABSTRACT FROM AUTHOR]

The 'Modern Matron' is one of the prominent nursing roles to emerge from the NHS Plan. The underpinning principle is to have a professional leader who is accountable for co-ordinating safe, high-quality care to improve patients' NHS experience. This paper discusses findings from a study of the implementation of the Modern Matron role in an acute NHS Trust in the East of England. The theoretical framework of 'limiting harm' was used to assess the extent to which the Modern Matron could contribute towards safe effective care and the reduction of harm. The study found that error-prone situations were clearly identified and that the Matrons were perceived to have a positive impact on a range of clinical issues. The evidence from this small study suggests that the Modern Matron role has the potential to make a positive contribution to patient safety. [ABSTRACT FROM AUTHOR]

In this paper, I aim to re-establish the meaning and importance of the concept of 'evidence-based policy making' (EBP) in health care. The term EBP is often misunderstood as being either vacuous (who thinks that public policy should not be based on evidence?), unrealistic (the naive product of ivory tower thinking) or conservative (an excuse permanently to delay reform). It need be none of these things. EBP should be thought of as a set of rules and institutional arrangements designed to encourage transparent and balanced use of evidence in public policy making. As well as controlled trials and observational studies, a broad range of theoretical and empirical evidence about human behaviour may be relevant to predicting policy outcomes - including stakeholder opinions and other sources of intelligence that might not qualify as scientific research. Gradual progress towards EBP, properly understood, has the potential to facilitate open democracy and to improve policy outcomes. The argument is illustrated using examples based on large-scale policies of health care reform in England, where progress towards EBP over the last decade has been real but modest. [ABSTRACT FROM AUTHOR]

This review of British government policy on accommodation for people with learning disability compares two White Papers: Better Services for the Mentally Handicapped (DHSS, 1971) and Valuing People (DOH, 2002). NHS employment issues muted the influence of Better Services. Statistics show a slow transfer from the NHS to other providers, but little development of independent living alternatives since 1971, despite a policy emphasis on social inclusion themes in recent policy. Promotion of housing choice, where residential care provision dominates, inhibits inclusive housing. Valuing People does not address the potentially conflicting choices of disabled people and their families and is critical of local authorities for not supporting large-scale residential care. Supported living alternatives cannot receive sufficient support where residential care agencies' interests predominate. Better incentives are needed for local authorities to provide support for people with learning disabilities to safely live in a home of their own rather than in residential care. [ABSTRACT FROM AUTHOR]

This paper addresses the theme of interprofessional education for health and social care professionals as it affects the development of the workforce. The drivers for change in the UK, typified by the Bristol Royal Infirmary and Victoria Climbié inquiries and the response to these in the form of Department of Health policy, are discussed. The need for rapid development of the evidence base around this subject is evident from literature reviews of the impact of interprofessional education. Directions for future research and investment in this area are proposed, including the need for a stronger theoretical base and for longitudinal studies over extended periods of time in order to examine short, medium and long-term outcomes in relation to health care practice. [ABSTRACT FROM AUTHOR]

Objectives: All health care providers in England are required to conduct surveys of their patients' experience of health care. Data from such surveys contribute to the 'star rating' performance indicators. However, there are concerns that these subjective measures may be influenced more by characteristics of patients than by true variations in the quality of care. The purpose of this paper is threefold: to determine the relationship between demographic characteristics and an index measure of patients' reported experience; to explore the extent to which patients' experiences may be accounted for by the particular National Health Service (NHS) trust they attended; and to assess how meaningful a summary index is in terms of its ability to discriminate between providers. Methods: Data from patients in the National Survey of National Health Service Patients treated for coronary heart disease in 194 NHS trusts. Patients were sent questionnaires after discharge, with a covering letter and a prepaid stamped addressed envelope. Up to two reminders were sent to non-responders. Multi-level linear regression models were used to estimate the extent to which patients' experiences differed between trusts and the association of demographic variables with the summary index. Results: In total, 116 872 patients were sent questionnaires, but 3399 proved to be ineligible for the survey. Responses were gained from 84 310 (74.3% of eligible respondents). Age and sex were most strongly associated with reported patients' experiences. However, the actual impact of age and sex on patients' experience is small, accounting for less than 3% of the variance. The proportion of the variance that was accounted for by the hospital trust in which patients were treated was only 5%. Conclusions: Demographic characteristics do not appear to account for differences between hospital trusts in patients' experience of health care. However, there is considerable variation in patients' experience within each provider. This would suggest that summary indices of patients' experience should not be used to rank providers, although detailed information from patient surveys have a useful role in determining priorities for quality improvement within individual hospitals and for assessing changes over time. [ABSTRACT FROM AUTHOR]

The interface between primary and secondary care in the UK has been affected by a number of recent changes, particularly in provision of out-of-hours care and advice. This paper reviews some current measures of healthcare quality and argues that many do not adequately measure contributions in primary care. To overcome these deficiencies the Royal College of General Practitioners (RCGP) has published guidelines on issues of quality in primary care. [ABSTRACT FROM AUTHOR]

Research can contribute to resolving some of the workforce challenges that all heath care systems face. In an attempt to identify the research agenda, key stakeholders in the UK were brought together and background papers were presented by academics with expertise in seven related but distinct areas: global issues; professional boundaries; education; regulation; workplaces; professional–patient interaction; and organisation and management. The research questions identified in each area are described along with some methodological challenges. It is hoped that this will encourage research in this crucial area of health services by facilitating a coherent approach to the diverse needs identified. [ABSTRACT FROM AUTHOR]

This paper contrasts the views of two prominent politicians on the ways in which the distribution of hospital services should be organised, and relates them to the views of Hayek on the nature of planning. It is argued that, in relying on an independent regulator to supervise access to health care under the new 'foundation' hospitals regime in the English National Health Service (NHS), not only is the Labour government distancing itself clearly from old-style top-down planning, it also risks greater variability in the definition of fair access to health care. There are relevant historical parallels with the mixed economy of the pre-NHS era that policy-makers should make explicit. [ABSTRACT FROM AUTHOR]