Search

This paper discusses margins in the context of building services, where the capacity in many buildings, such as hospitals, exceeds the requirements by huge amounts. This oversizing has a direct impact on building efficiency, capital, maintenance and operational costs, as well as environmental and societal impacts throughout its lifecycle. This paper analyses two in-depth case studies of oversized boiler and chiller systems within NHS hospitals, whereby a number of key factors leading to the oversized systems are identified. The excessive and uncoordinated use of margins that are applied during the various stages of building service projects for a variety of reasons, is one significant factor. The lack of requirements information such as energy demand profiles and the use of vague and unreliable data for initial project requirements specifications, is also a major contributing factor. The paper points to the need to develop robust processes that capture the scope and rationale for the margins applied, to communicate project assumptions and stakeholder requirements in a clear and unambiguous format and to develop systems for improved data capture and analysis. [ABSTRACT FROM AUTHOR]

Visual acuity (VA) screening in children primarily detects low VA and amblyopia between 3 and 6 years of age. Photoscreening is a low-cost, lower-expertise alternative which can be carried out on younger children and looks instead for refractive amblyopia risk factors so that early glasses may prevent or mitigate the conditions. The long-term benefits and costs of providing many children with glasses in an attempt to avoid development of amblyopia for some of them needs clarification. This paper presents a framework for modeling potential post-referral costs of different screening models once referred children reach specialist services. The EUSCREEN Screening Cost-Effectiveness Model was used together with published literature to estimate referral rates and case mix of referrals from different screening modalities (photoscreening and VA screening at 2, 3–4 years and 4–5 years). UK 2019–20 published National Health Service (NHS) costings were used across all scenarios to model the comparative post-referral costs to the point of discharge from specialist services. Potential costs were compared between a) orthoptist, b) state funded ophthalmologist and c) private ophthalmologist care. Earlier VA screening and photoscreening yield higher numbers of referrals because of lower sensitivity and specificity for disease, and a different case mix, compared to later VA screening. Photoscreening referrals are a mixture of reduced VA caused by amblyopia and refractive error, and children with amblyopia risk factors, most of which are treated with glasses. Costs relate mainly to the secondary care providers and the number of visits per child. Treatment by an ophthalmologist of a referral at 2 years of age can be more than x10 more expensive than an orthoptist service receiving referrals at 5 years, but outcomes can still be good from referrals aged 5. All children should be screened for amblyopia and low vision before the age of 6. Very early detection of amblyopia refractive risk factors may prevent or mitigate amblyopia for some affected children, but population-level outcomes from a single high-quality VA screening at 4–5 years can also be very good. Total patient-journey costs incurred by earlier detection and treatment are much higher than if screening is carried out later because younger children need more professional input before discharge, so early screening is less cost-effective in the long term. Population coverage, local healthcare models, local case-mix, public health awareness, training, data monitoring and audit are critical factors to consider when planning, evaluating, or changing any screening programme. [ABSTRACT FROM AUTHOR]

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness. It is considered as an important public health issue, and prevalence of diagnosis has increased as awareness of the disease grew over the past years. Supply of specialist medical experts has not kept pace with the increasing demand for assessment, both due to financial pressures on health systems and the difficulty to train new experts, resulting in growing waiting lists. Patients are not being treated quickly enough causing problems in other areas of health systems (e.g. increased GP visits, increased risk of self-harm and accidents) and more broadly (e.g. time off work, relationship problems). Advances in machine learning make it possible to attempt to diagnose ADHD based on the analysis of relevant data, and this could inform clinical practice. This paper reports on findings related to the mental health services of a specialist Trust within the UK's National Health Service (NHS). The analysis studied data of adult patients who underwent diagnosis over the past few years, and developed a diagnostic model for ADHD in adults. The results demonstrate that it is indeed possible to correctly diagnose ADHD patients with promising statistical accuracy. [ABSTRACT FROM AUTHOR]

Campaigns against the privatisation of healthcare in the UK have often focused on saving, or preserving, the post-war National Health Service (NHS) of the 1950s. They talk of it as a 'national treasure', which has long given the UK some moral high ground over countries such as the United States. I argue that seductively simplified campaign slogans can also be blunt – they can carry with them more opaque messages such as those that encourage the maintenance of a patriarchal healthcare system. As a result, campaigns to save the NHS of the 1950s also preserve the nationalism, as well as the class and gendered staffing hierarchies, which (as I illustrate) come to reproduce inequalities in the care that is delivered. Through a multi-cited ethnography focused on the delivery of hip replacements in the NHS, I argue that a more complex form of political activism is needed to bring about the equality in healthcare that the NHS promises. In this paper, I flatten assumed hierarchies of power, to highlight some ethnographic examples of how everyday actions can come to reshape antiquated power structures. I conclude by suggesting we look to how power is pieced together across networks – and how we can re-locate collective agency to within and amongst ourselves to bring about a more equal, and less nationalistic, healthcare service. [ABSTRACT FROM AUTHOR]

The role of lifestyle on mental health in the ambulance worker population is unclear. The aim of this paper is to explore the role and impact of lifestyle on the mental health of ambulance workers within the United Kingdom (UK). Participants (N = 160) were recruited from 4 NHS ambulance trusts in England. Data were collected on lifestyle factors (sleep, physical activity and alcohol use) and mental health outcomes (trauma, anxiety, depression and stress); these were assessed by use of various questionnaires including validated measures. Sleep was shown to be the single biggest unique and significant predictor to all mental health outcomes. Suggestions for future research and intervention are considered. [ABSTRACT FROM AUTHOR]

The UK's publically available blood stem cell infrastructure has undergone significant transformation in recent years as umbilical cord blood has joined adult donors as a viable clinical stem cell source. This paper describes the development of a collaborative governance arrangement between the UK's two domestic providers of blood stem cells: a public body and a charity. The paper argues that the collaborators, who stand to benefit from the alignment, legitimize their work through appeals to public good. It suggests that appeals to buy British obscure an inevitable requirement to cultivate international, networked stem cell exchange; the paper also explores collaborators' reinforcement of a supposed connection between human leukocyte antigen tissue type and ethnicity through claiming that the UK's ethnic minorities face an “unmet need.” By way of this, the paper demonstrates the interconnection of collaborators' institutional interests with concerns for national health equity. [ABSTRACT FROM PUBLISHER]

Produced and published by the coalition government, the publication of the 2014 Special Educational Needs and Disability Code of Practice: 0-25 years (2014 SENCoP) sets out to overhaul the management of special educational needs (SEN) provision across England and Wales. This paper employs a critical discourse analysis (CDA) of the 2014 SENCoP to reveal the ideologies and aims that this policy is built upon. Following a Foucauldian framework of governmentality, this article focuses upon the way in which 'a successful transition to adulthood' is constructed within the policy, particularly in relation to the wider Conservative narrative of a 'Big Society.' Developing this analysis, the article draws upon the current political landscape of a Conservative government and the shift towards the creation of a 'shared society' in attempt to locate 'adulthood' within its wider political, economic, and cultural context. This analysis reveals the neoliberal values underpinning the 2014 SENCoP, whereby educational support is reduced to the practice of shaping and sculpting the future generation of citizens. By deconstructing notions of employment, independence, participation, and health, this article reveals the 2014 SENCoP as a tool of government, written to the demands of the economy rather than the unique needs, aspirations, and ambitions of children and young people labelled with SEN. [ABSTRACT FROM AUTHOR]

The need for support for good mental health is enormous. General support for good mental health is needed for 100% of the population, and at all stages of life, from early childhood to end of life. Focused support is needed for the 17.6% of adults who have a mental disorder at any time, including those who also have a mental health problem amongst the 30% who report having a long-term condition of some kind. All sectors of society and all parts of the NHS need to play their part. Primary care cannot do this on its own. This paper describes how primary care practitioners can help stimulate such a grand alliance for health, by operating at four different levels – as individual practitioners, as organisations, as geographic clusters of organisations and as policy-makers. [ABSTRACT FROM PUBLISHER]

This study examines direct-to-consumer genetic testing (DTCGT) in the UK using the Social Construction of Technology framework to draw conclusions about how commercial genotyping is being shaped by principal groups involved with the technology. Different tests are available including single nucleotide polymorphism genotyping for ancestry and health information, the latter being the focus of this study. I conducted interviews with DTCGT users, and genetics clinicians who had either been consulted about DTCGT or who were willing to discuss their views. This paper is about one of the study’s three themes, the NHS. DTCGT seemed to provide a point of focus for conflict between personalized and collective medicine in the UK, rather than being its cause. This suggests that DTCGT is more likely to achieve stability by virtue of being superseded by new technologies, rather than by achieving closure. [ABSTRACT FROM AUTHOR]

Hospital in the home is a relatively new concept within the UK healthcare system. The Guy’s and St Thomas’s NHS Foundation Trust (GSTT) @home service ‘Bringing hospital care to your home’ was commissioned by Lambeth and Southwark CCG in 2014 to provide acute care in the patients’ place of residence by facilitating rapid discharge from hospital. The service is designed for 260–280 referrals each month from local hospitals, London Ambulance Service, GPs, district nurses and palliative care services. The GSTT@home provides intensive care for a short episode through multidisciplinary team work with the aim of returning the patient to their prior health status following an acute episode of ill health. The main criteria for referrals are adults, living within Lambeth or Southwark with an acute onset of illness often with acute exacerbations of chronic conditions. Care is delivered using 25 clinical pathways using integrated care teams, including those for respiratory disease, heart failure and palliative care services. Recently, the service extended to include overnight palliative care. As care shifts from hospital to the community, it is envisaged that these types of programmes will become an essential component of care provision. This paper describes the service and presents initial service evaluation data. [ABSTRACT FROM AUTHOR]

The concept of complex trauma has been around for a long time and in 2018, it's expected to become a new diagnosis in the International Classification of Diseases eleventh revision, ICD-11, the World Health Organisation, WHO, manual used formally in the NHS. Psychiatric diagnosis often does not sit well with psychoanalysis, which is at least as interested in unconscious phantasy as it is in symptoms. But as psychodynamically-trained practitioners in the NHS we need to engage with ICD-11 and apply our own understanding to service design so that patients have access to treatment which works for them. The service where I work (a secondary mental health team in the London borough of Lewisham) has already been receiving referrals for 'complex trauma' for some time, despite its not being formally classified. Patients so described are most often those with a history of childhood sexual abuse, and refugees with a history of brutality and torture. Differential diagnosis includes personality disorder since many have difficulties with interpersonal issues. In this paper I want to discuss how we might understand the new diagnosis of complex Post-traumatic Stress Disorder, PTSD, and its implications for treatment in the NHS. [ABSTRACT FROM AUTHOR]

An NHS Mental Health Trust Medical Psychotherapy Consultation Service using psychoanalytic psychiatry to help the patient and professional is described. The Consultation Service established in 2000 is offered to secondary acute and community mental health teams and primary care. The service was evaluated as a basis for regional and national development. Between 2006 and 2013, 87 consultations from 210 were sampled to ascertain demographic and diagnostic profiles and outcomes of the consultation process. We conducted an online survey of local consultant psychiatrists' views about the service, and undertook a thematic analysis of the free text comments. We also conducted a survey of members of the Royal College of Psychiatrists' Medical Psychotherapy Faculty to ascertain whether similar consultation services existed elsewhere in the UK and had been evaluated. The Leeds model of psychoanalytic consultation – a 'consultation sandwich' – is described. From a psychoanalytic perspective, the work of consultation is seen as an extension of the dynamic field of the analytic situation. This paper develops the concept of a bastion – an omnipotent reserve in and between the patient and professional derived from adhesive identifications leading to stuck relationships. The adhesive identification in the patient and professional acts like a 'grievance glue' – a mutual manifestation in a last bastion of painful limitations not faced, losses not grieved. [ABSTRACT FROM AUTHOR]

This paper considers the extent, experience and consequences of living with neophilia in the English National Health Service (NHS). Drawing on notes from an ethnographic case study of a new partnership between doctors and nurses in primary care, this paper considers how a fetish for novelty may both drive and destroy developments in organising. The context for the study is a national system driven by the demands of neophilia for over a quarter of a century. It is a system in which new answers to persistent problems of access, cost and equity are sought through innovation, novelty and change. Yet the results of each new change are disappointing as old problems re-emerge and national-level neophilia appears defunct. Searching for an alternative to the dysfunctional aspects of nationalised neophilia, this paper focuses on the possibility of engaging more localised experiences of innovation in organising. Employing Douglas' grid-group model of cultural theory, this paper explores the attempts of a group of doctors and nurses to develop the New Partnership. The partnership is shown to be new in so far as it stands as an example of that which Douglas defines as an egalitarian enclave, challenging dominant traditions of organising. However, it soon becomes clear that a fetish for innovation on the part of local neophiliacs is no less problematic than for their national counterparts. In a contribution to our understanding of neophilia, this paper considers how an accounting for different organising cultures can help to explain and possibly pre-empt the processes and problems of living with newness. [ABSTRACT FROM AUTHOR]

This paper explores the concept of the 'Gold Effect' in relation to the use of serum cholesterol measurement as a screening test for cardiovascular disease. The Gold Effect explains the phenomenon of the process by which an idea comes to be held as a generally accepted truth. In this paper we argue that cholesterol screening is the product of the Gold Effect. Screening tests need to be sufficiently robust as an indicator of risk and thus their evidence base should be clear and uncontested. While there has been a long standing debate about the link between high cholesterol and cardiovascular disease and, in particular, the use of statins as the main approach to lowering cholesterol levels, serum cholesterol measurement and lowering levels of cholesterol are widely accepted as NHS interventions and are financially incentivised. We start by discussing what cholesterol is and how it is screened for in the UK. We then go on to examine the evidence for using cholesterol as a risk marker for cardiovascular disease. We then discuss the research on reducing cholesterol levels through diet and by using statins. We finish by discussing the implications of this analysis and questioning why cholesterol is routinely screened for and why so much emphasis is placed on cholesterol reduction arguing that at the root of this approach there is a misconception about the relationship between fat and cholesterol and about the role of cholesterol in cardiovascular disease. [ABSTRACT FROM AUTHOR]

This paper explores the dilemma faced by many current analytic practitioners, particularly in the National Health Service. With the elevation of the idea of 'evidence-based practice' as the increasingly dominant mode of discourse, is it better to try to preserve one's analytic identity and practice by keeping to the psychodynamic model, or is there a case for seeking accommodation with other therapies, even if they are non-analytic? This paper describes the author's experience in pursuing the latter course, in learning a form of therapy called Interpersonal Psychotherapy. The author describes a piece of work using Interpersonal Psychotherapy, and then attempts to give a psychoanalytically informed reading of the same material. The aim is to suggest that although a perfectly adequate account can be given of this clinical work in terms of Interpersonal Psychotherapy, the therapeutic process can also be understood in terms of movements in the transference and in the patient's intra-psychic world. It is finally suggested that adding a psychoanalytic dimension to such a non-analytic therapy may enrich one's practice not only of these other therapies but also of analytic therapy itself. [ABSTRACT FROM AUTHOR]

This paper presents the findings of original research into the competencies, or behavioural repertoires, of board-level communicators in the UK National Health Service (NHS). Eight core competencies specific to that group were discovered and these are presented along with the supporting behaviour sets. The paper compares and contrasts these competencies with those of communicators in other public sector organisations and with a group drawn from the private sector. While the research found that there are a large number of similarities between the NHS and these other sectors, there are a number of significant differences. The paper discusses these differences in depth. Communication practitioners aspiring to take on a board-level role in the NHS will need to learn these behaviours and enact them if they wish to be successful in their search for promotion. Similarly, board-level communicators who wish to equip their team with higher-level competencies in readiness for promotion to senior levels can use the research as a blueprint for coaching and training. The paper concludes with recommendations for further research. [ABSTRACT FROM AUTHOR]

Despite an increasing number of policies and guidelines relating to psychological therapies within the NHS, there is little clear evidence of many of the intended benefits actually accruing from their implementation. Drawing on the work of Tom Main and others, this paper examines some of the emotional and unconscious factors, in both staff and patients, which determine the fate of policies and specifically the extent to which they become authentically embedded within a hospital system. Unanticipated or unintended effects of past policy implementation in relation to borderline personality disorder are discussed in the context of secondary and tertiary level NHS psychotherapy services. These effects include the risk that the latter services become sidelined by cheaper initiatives and interventions at primary care level, irrespective of the evidence base in relation to borderline personality disorder. Given the financial and human costs of policy failure, the paper proposes a significant and active role for psychodynamic psychotherapists in promoting a more thoughtful approach to local policy implementation so as to lead toward a service that is genuinely patient-centred. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to promote thought and discussion around how and why we treat patients in chosen ways. In the present climate practitioners are required to treat patients following NICE guidelines in which cognitive behavioural therapy (CBT) is the treatment of choice in the majority of diagnoses. This paper raises concerns that this may lead to an homogenization of treatment, loss of invaluable skills and understanding from other treatment approaches, and loss to the patient who may be best cared for by a combination of treatments and approaches, most notably patients presenting with complex pathology. This paper aims to present this as a general principle, and by way of example, will focus on coupling two specific treatment orientations, cognitive behavioural therapy with psychodynamic psychotherapy, with the specific diagnosis of obsessive compulsive disorder (OCD). Methods: Clinical material is drawn from case studies from practice in secondary adult mental health care services within the NHS. All patients were referred to the psychological services for treatment for OCD and provided with 1:1 therapy with UKCP-registered therapists. Details have been anonymized by describing fictitious cases re-constructed from clinical material. A theoretical understanding is included which provides both an overview for integrating treatment for the specific example of OCD and is intended by extension to other diagnoses. Results: Working with the commonalities of therapeutic approaches, and integrating specific skills of CBT and psychodynamic psychotherapy, appears to offer a viable mode of treatment for cases resistant to single-orientation therapies. Conclusions: Coupling the skills of different therapies can be effective in treating complex patients that are referred to the secondary mental health services. Conversely, restricting practice to single orientation therapies can lead to an impoverished care for patients and diminution of invaluable therapeutic skills which may become underused, undervalued and lost in the practice of mental health care within the NHS. Acknowledgement of the skills of others, valuing these and learning from each other can help to avoid the defensive reactions of practitioners, where each may defensively retreat to their corners of specialism. Respecting and sharing skills from different orientations, and acknowledging this in the NICE guidelines, is good for both mental health services and patient care and addresses the concerns raised by practitioners exemplified by Bateman (2000, p. 147) that 'psychotherapy continues to be bedeviled by ideological schisms with practitioners apparently ignoring alternative conceptualizations and potentially superior interventions'. [ABSTRACT FROM AUTHOR]

This paper gives an account of learning, which occurred as a result of occupational therapists piloting a new occupational therapy service in two mainstream schools in a socially deprived area of the South East of England. The paper explores how therapists, familiar with working within the National Health Service, developed new approaches and understandings of their role, in order to meet the challenges of working as part of a team in a mainstream school. The paper considers how new understandings have led therapists to contemplate changes in their practice and possibilities for the future development of the occupational therapy service. [ABSTRACT FROM AUTHOR]

This paper outlines the way in which professional self regulation of quality of healthcare was integral to the creation of the National Health Service (NHS) in 1948, and to the way the NHS was organized for the next 50 years. It describes the crisis in quality that emerged in the late 1990s. It describes the government's initial responses to that crisis, which were to require NHS organizations to implement systems of clinical governance, and create the Commission for Health Improvement (CHI) to inspect its implementation through visits to each NHS organization. The paper discusses Reports from Inquiries into three scandals, and considers the further changes made to governance and regulation of quality with the abolition of CHI and the National Care Standards Commission, which inspected the private sector, to be succeeded by the Healthcare Commission with a new approach to regulation. It examines three promises of that new approach: the use of national standards; being 'light touch' and proportionate using 'intelligent' (or 'smart') information, as opposed to being organized on a comprehensive programme of visits; and developing a common approach to the NHS and private sectors. [ABSTRACT FROM AUTHOR]

The article presents the authors' comments in response to the paper entitled "Distinguishing surveillance from research," by G. Sherman and J. Campione-Piccardo. They say that the paper analyzes the methodological and conceptual differences between surveillance and research projects, and argue that the difficulty in distinguishing the types of activity for the Great Britain National Health Service Research Ethics Committees' review is highly expressed. They likewise address the need to clarify the definitions of research and audit so that investigators will be clarified. Moreover, they suggest the importance of clarifying the distinction between surveillance and research in a published debate.

This paper outlines the processes of quality assurance of GP appraisal in Wales. These processes demonstrate the application of national guidance for quality assurance of medical appraisal as recommended by the National Clinical Governance Support Team (NCGST). The paper describes how defined standards of practice in the context of GP appraisal have, on a relatively large scale, been developed and demonstrated through robust internal and external quality assurance mechanisms. These quality assurance mechanisms reveal positive feedback from the vast majority of participants in the process. Both GPs and appraisers report that they benefited from their involvement in appraisal. The study demonstrates that the outputs of appraisal (summary and personal development plan) accurately reflect the content of the appraisal and help doctors to plan their learning, although further work is required with respect to specifying action plans. [ABSTRACT FROM AUTHOR]

Health and social care education has a long established association with reflective learning as a way of developing post‐qualifying professional practice. Reflective learning is also a key feature of self‐regulatory learning, which is an essential aspect of life‐long learning for today’s National Health Service workforce. Using a small‐scale case study of practice this paper considers the experiences of 25 learners who, as qualified health and social care practitioners studying a B.Sc. (Hons.) Public Health programme, used Blackboard to reflect online. Questionnaires, a focus group discussion and examination of online dialogue were used to collect data. Findings suggest that learners developed more extensive reflective accounts than they had done previously when reflecting in traditional classroom environments. They reflected further, spent longer reflecting, self‐managed their reflective learning and recognised significant learning achievements through reflection. Data indicate varying levels of engagement in the online reflective process, with not all learners achieving a deep level of critical analysis. This paper considers the design and construction of the online learning activity and environment before discussing the findings of the evaluation and implications. [ABSTRACT FROM AUTHOR]

This paper examines how responsibility for the planning of state-funded HIV prevention services shifted from UK central government to local commissioners during the 'era of normalization' in the 1990s. It explores whether according to literature from the period these changes experienced were those that would be predicted by theories of 'advanced liberalism', i.e. delegation of operational planning, centralization of strategic target setting, and increased scrutiny of 'expert' providers. The paper examines the changes that were described in power relations among key players, using advanced liberalism to structure this examination. The paper concludes that many but not all of the reported changes conformed to these predictions. Although the government did set targets, these targets did not function as effective levers on local activity. Although delegation of planning to local commissioners did occur, their authority was restrained by the retention of specific earmarked HIV prevention funding. Although scrutiny was applied to those with expert status providing services, some—especially those in the voluntary sector—appear to have been scrutinized more than others, such as various clinical practitioners. [ABSTRACT FROM AUTHOR]

The concept of the ‘risk society’ has focused on growing uncertainties about the benefits of scientific innovation and the reliability of professional judgement. Paradoxically, this has gone hand in hand with reductions in the actual risk associated with many activities and is often accompanied by demands for a technological fix. These contradictory impulses are especially evident in maternity care. While maternal and infant mortality rates have fallen, risk conscious patients are increasingly concerned about the possibility of professional mistake or malpractice. As a result, further categories of risk are created for organizations and professionals, particularly in relation to expensive litigation. Against this background, the paper reports on an ethnographic study of two delivery suites in which a computerized decision support system will be implemented. In the paper, we attempt to highlight some of the intricacies of work processes in delivery suites, specifically involving decision-making, risk, uncertainty, professional autonomy and medical knowledge. Our findings suggest a range of complexities that may considerably complicate the implementation of the computerized decision support system when it finally emerges and becomes embedded in delivery suites. [ABSTRACT FROM AUTHOR]

Abstract The variable nature of NHS provision of fertility services has again been highlighted by the response of commissioners to the recent guidance from the National Institute of Clinical Excellence. This paper describes an evidence-based model for policy aimed at minimising inequity across one Strategic Health Authority. The paper highlights the difficulties resulting from the current Department of Health guidance on targeting those in greatest need. A different way of describing this group is proposed, namely, defining childlessness in terms of parental status alone. This is clear to both patient and clinician at the outset, not subject to variable interpretation and because it is quantifiable for any given population, facilitates the commissioning of a level of service provision that reflects expressed need. A clinical audit suggests that the annual incidence of fertility problems prompting attendance at secondary care clinics is similar to levels observed nearly 20 years ago, at around 98 per 10,000 of the fertile population (proxy denominator, women aged 25  –  39). Our model further indicates that, for the more complex treatments, if both partners were required to be childless and treatments were to be delivered within 12  –  18 months of listing, commissioners would need to fund treatment for around 15  –  20 patients per 10,000 of the fertile population. If only one partner was required to be childless this figure would rise by 15  –  20%. We argue that despite the clinical guidelines, fertility treatments will remain a ‘postcode lottery’ unless central government addresses the priority to be given to fertility treatment on a national basis. [ABSTRACT FROM AUTHOR]

International recruitment now forms an important part of the government's policy to increase capacity in the NHS.1 By 2003, 89 general practitioners (GPs) had been recruited from countries of the European Union (EU), and in particular, Spain and France.2 The ability of the NHS to retain these GPs will, in part, depend on the support that they receive during the transition to work. In order that this can be achieved, the Department of Health recommend that all overseas doctors should participate in a thorough and comprehensive induction programme and receive support until they are fully integrated into the NHS.3 This paper describes the stages that we went through to develop an induction programme for EU GPs and reports on the programme evaluation. Evaluation of the programme has largely been positive, with most GPs suggesting that they would never have come to work in London general practice without the support of a formal programme that facilitated their transition to work in the NHS. Some components of the programme, for example facilitated peer support, provided unexpected outcomes, offering participants the opportunity to develop a supportive, cohesive team. Other aspects of the programme, for example the clinical placements, sometimes provoked an initial loss of confidence as participants found it difficult to move into a learning role, having previously been practicing ‘unwatched’ for many years. Programme evaluation also indicated that French GPs are generally not accustomed to self-directed continuing education or professional development. In order to maximize learning from the induction programme, therefore, participants tend to require clear direction regarding private study. At the time of writing this paper, 33 GPs have attended the programme, 26 (79%) of whom have taken up employment in London general practice. [ABSTRACT FROM AUTHOR]

This paper applies Jessop's analysis of the new political economy of welfare to the case of the NHS, exploring the insights into the changes in health policy in the UK that such a perspective offers. Alongside Jessop's analysis, the paper also considers the competing tension of path dependency in health policy, and the possibility of alternative futures to those envisaged in Jessop's model. [ABSTRACT FROM AUTHOR]

The UK government has stated within its plan of reform for the National Health Service that a secure system for the Electronic Transfer of Prescriptions will be available by 2004. The objectives of this paper are to highlight the significant barriers faced in securing an ETP system, to provide a critical analysis of the security mechanisms in the models currently being piloted and to suggest an alternative revised model which overcomes the identified deficiencies and security hurdles. To identify the significant security issues relevant to the adoption of ETP, the authors have combined their analysis of present prescription processing practice with their knowledge of computer security. The authors identify and describe how the issues of patient confidentiality, authorization, identity authentication, audit, scalability, availability and reliability are significant barriers to the adoption of ETP, particularly if they effect ease of use. The paper's contribution to the field of ETP is to suggest solutions to each of the identified security issues and to combine the solutions together in a revised and developed model. [ABSTRACT FROM AUTHOR]

This paper develops and updates an earlier paper in this journal on freedom of speech for National Health Service (NHS) staff (Vickers, 1999). It focuses on the importance of political speech for those who work in the NHS, in the light of the major increase in spending on the NHS announced by the Chancellor of the Exchequer in the 2002 budget. It argues that the speech of those who work in the NHS is of great political importance and assesses the extent to which this would be recognized in legal action that might be taken against staff who engage in political debate. In particular, the implications of the changes to the professional duty of confidence owed by nursing staff in the new Nursing and Midwifery Council Code of Conduct, introduced in June 2002, is considered. Relevant new case law under the European Convention on Human Rights (ECHR) is also considered. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this paper is to identify lessons for the National Health Service that can be learnt from previous organisational experiments. The paper draws on an evaluation of the purchasing of mental health services by Total Purchasing and Extended Fundholding sites. These are the closest previous models to the newly emerging Primary Care Groups and Trusts. We aimed to determine what primary care practitioners tried to achieve when given a budget for purchasing secondary care mental health services, and what determined whether or not they were successful in achieving their objectives. Methods: The study involved an initial telephone survey of 40 sites (27 Total Purchasing, 13 Extended Fundholding). Six 'special study sites' were then selected for in-depth study. Follow-up questionnaires were sent to the remaining 34 sites and responses were received from 25 (18 Total Purchasing, seven Extended Fundholding). The overall response rate from the 40 sites was 31 (78%). Findings: Primary care purchasing produced better communication and improved working relationships between primary and secondary care. This was less evident with social services, except where initiatives were jointly funded. Setting budgets was difficult, but holding a budget was seen as important in changing service provision. The main change in service provision was that more mental health staff were located in primary care settings. Detailed contracts were rarely used as the method of producing change. User involvement was notable by its absence. The challenge for PCG/Ts is to roll out perceived benefits achieved in Total Purchasing experiments in mental health to larger populations, balancing the drive for high quality services with equitable distribution of care. This will require clear and effective management of communication between stakeholders at an increasingly complex interface. [ABSTRACT FROM AUTHOR]

The introduction of Clinical Governance into the National Health Service in England represents a fundamental shift in the regulatory relationship between the state and medical professionals. This paper critically examines the underlying assumptions of Clinical Governance, and discusses them in relation to Foucauldian concepts of 'governmentality'. First, official definitions of Clinical Governance are reviewed in the context of other policies to apply increased control and surveillance to medical professionals and linkages between this and wider tends in public sector managerialism and governance. The paper then briefly considers these developments in relation to theoretical accounts of bureaucracy, professionalism, risk and trust. It is argued that at the organisational level, Clinical Governance can be usefully analysed as involving a move towards 'encoded knowledge' through the use of 'soft bureaucracy'. [ABSTRACT FROM AUTHOR]

This paper reports the findings from an evaluation of a pilot interprofessional training ward project for pre-qualification medical, nursing, occupational therapy and physiotherapy students. This initiative required sustained collaboration from staff based in two National Health Service (NHS) trusts and four schools in three universities. The ward was based on a model of interprofessional education developed in Sweden, but adapted in the light of this experience and also to meet the needs and aspirations of the training ward stakeholders in London. The training ward was evaluated using a multi-method design. Data were collected from all participants involved in this pilot: students, facilitators and patients. The findings from the evaluation are presented and discussed. This paper pays particular attention to the collaborative experiences of the students, staff and institutions involved in this initiative. In addition, 1-year follow-up data collected from the students who had, by then, qualified as clinical practitioners are reported. The paper presents conclusions from the evaluation, and comments on the training ward's strengths, limitations and future development. [ABSTRACT FROM AUTHOR]

This paper discusses the topic of the relationship between organisational structure and information and communication systems by presenting a study of the organisational changes currently underway in the provision of NHS cancer services in the county of Kent. The paper describes the reasons for considering changes in the provision of services and outlines the major direction of change. It then links an earlier concern of information systems designers with 'Business Process Re-engineering' with the current concern with e-commerce and the redesign of systems prompted by the popularity of the Internet. It then presents possible organisations of an information system for a networked cancer service based on current organisational models used in e-commerce. [ABSTRACT FROM AUTHOR]

This paper looks at the process of Private Finance Initiative (PFI) planning in the UK National Health Service, and addresses the extent to which it ensures the adequacy of service provision. The Private Finance Initiative is intended not only to substitute private for public financing of healthcare facilities, but also to produce efficiencies in the operation of these healthcare services through the introduction of innovatory private sector practices. The paper contrasts the traditional capital-planning process within the health service, which was based on estimates of service need, with the PFI planning framework, which is finance led. PFI planning also has to be seen in the context of other organizational and financial reforms within the health service which have increased the pressures on health trusts to operate like commercial businesses and to rationalize service provision to meet financial targets. Drawing on a series of interviews and documentary sources, the paper shows how these pressures, coupled with the tendency of PFI to increase capital costs, have led to drastic actual and planned cuts in services not only in the facilities directly affected by a particular PFI but also in other areas of local healthcare provision which have not been justified by detailed analysis of projected healthcare needs. [ABSTRACT FROM AUTHOR]

In 1992 the author described her experience of working in a newly formed acute NHS Trust hospital. One of the key messages of the paper concerned the pace of radical changes experienced. Eight years on, the process of change has accelerated still further, and healthcare professionals working in the NHS face newer and tougher challenges with regard to funding, recognition and survival. This paper describes the author's personal view of developments so far. [ABSTRACT FROM AUTHOR]

Since its election in 1997, the UK Labour Government has called for collaboration on an unprecedented scale throughout the public sector. This paper focuses upon collaboration in and surrounding the National Health Service (NHS), with reference to implications for higher education. It urges universities to enter into the new spirit of partnership with one another and with the NHS. The paper is based upon my inaugural lecture delivered on 13 April 1999 as a Visiting Professor at the University of Greenwich, UK. [ABSTRACT FROM AUTHOR]

This paper describes the new approach being taken to quality improvement and assurance in the UK through clinical governance. The purpose is to identify what is required to make clinical governance work. The paper outlines an underlying set of themes within clinical governance and establishes the central role of interprofessional collaboration in achieving policy aims. It discusses the role that new accountabilities may play in supporting the development of clinical governance in secondary care and the need to consider networks of accountability as an effective way of underpinning collaborative effort. It is argued that a strong backbone of accountabilities will help generate the culture of collaborative working that is necessary to achieve clinical governance objectives. The paper highlights three areas where there are weak links in the chain of accountability. [ABSTRACT FROM AUTHOR]

This paper examines the importance of inter-professional collaboration in the introduction and development of NHS Direct - the new National Health Service telephone triage service. The service currently has a narrow role providing telephone advice and information to self-selected callers, but could be developed to fulfil a wider set of functions. To do this will require support and co-operation from general practitioners and other primary care professionals, many of whom have been alienated by the rapid introduction of the service without consultation. The paper presents findings from interviews with health professionals involved in setting up NHS Direct at two London sites. It explores the consequences of limited professional commitment and highlights the ways in which collaborative work between health care and other professionals could contribute to the future development of NHS Direct. [ABSTRACT FROM AUTHOR]

In this paper, we examine why risk-based policy instruments have failed to improve the proportionality, effectiveness, and legitimacy of healthcare quality regulation in the National Health Service (NHS) in England. Rather than trying to prevent all possible harms, risk-based approaches promise to rationalise and manage the inevitable limits of what regulation can hope to achieve by focusing regulatory standard-setting and enforcement activity on the highest priority risks, as determined through formal assessments of their probability and consequences. As such, risk-based approaches have been enthusiastically adopted by healthcare quality regulators over the last decade. However, by drawing on historical policy analysis and in-depth interviews with 15 high-level UK informants in 2013–2015, we identify a series of practical problems in using risk-based policy instruments for defining, assessing, and ensuring compliance with healthcare quality standards. Based on our analysis, we go on to consider why, despite a succession of failures, healthcare regulators remain committed to developing and using risk-based approaches. We conclude by identifying several preconditions for successful risk-based regulation: goals must be clear and trade-offs between them amenable to agreement; regulators must be able to reliably assess the probability and consequences of adverse outcomes; regulators must have a range of enforcement tools that can be deployed in proportion to risk; and there must be political tolerance for adverse outcomes. [ABSTRACT FROM PUBLISHER]

This paper examines a central image in UK academic clinical research – the patient as altruistic research subject – by means of an interpretive review of social science, bioethical and bioscience research and development policy literatures. The review examines this image as it is indicted in discussions about the nature of clinical science; is consolidated in the ethical regulation of this science; and is articulated in recent bioscience research and development government initiatives. Drawing on Strathern's notion of the virtual (public-sector) subject, the review identifies the anticipation of NHS patients as alternatively ‘available’ or ‘entitled’ to the expanding translational medicine industry. [ABSTRACT FROM AUTHOR]

The following paper describes the results of an empirical investigation into four different types of teamworking within an inner-city National Health Service (NHS) community trust in the UK. The four kinds of team were: (1) single-disciplinary (e.g. district nursing teams, health visiting teams); (2) multidisciplinary (a group of professionals working within a clinic or health centre); (3) management (e.g. planning and development teams); and (4) primary health care (a group of health professionals and support staff arranged around a general practice or set of practices). The present study involved a survey of 259 members of 30 teams. Nineteen of the teams were multidisciplinary clinic or health centre teams. Six of the teams were primary health care teams, two were single-disciplinary teams, and three were NHS management teams. Team members were surveyed during team building workshops with the Team Climate Inventory (TGI: Anderson & West, 1994) which measured team climate on four levels: participative safety; innovation; task orientation; and team vision. A one-way analysis of variance of the data collected from each of the 30 teams found statistically significant differences on two out of the four factors of team functioning. The present study uncovered similar findings to those obtained by West & Poulton (1997). The paper discusses the results in light of the UK government's White Paper on the National Health Service The New NHS: Modem, Dependable (Department of Health, 1997) and offers recommendations for resolving difficulties in primary health care teamwork. [ABSTRACT FROM AUTHOR]

This paper looks at the contribution that computers have made to the delivery of the National Health Service through a period of major reform that began in 1986, and is still ongoing. The paper starts with a retrospective analysis of the first generation of NHS Reforms and the role played by computer systems. The major empirical component is a case study looking at the impact of computers on health promotion activities among over 1 million patients in Lancashire. Finally, the paper looks forward to the latest NHS reforms, as outlined in the 1997 White Paper The New DHS (Department of Health, 1997, HMSO, London) and outlines the information implications and a strategic framework to deliver changes required if the reforms are to succeed. [ABSTRACT FROM AUTHOR]

This paper traces the development of physiotherapy as a career for visually impaired people from the end of the 19th century until the present day; It is an aspect of the author's on-going PhD research into the employment situation of visually impaired physiotherapists. Visually impaired physiotherapy students were initially integrated with their sighted peers, but from 1915 their training was taken over by the Royal National Institute for the Blind within a segregated college. This arrangement lasted until 1992 when visually impaired students were accepted for training as physio therapists at the University of East London. This paper traces difficulties visually impaired people have experienced in their struggle for acceptance and survival within the physiotherapy profession, and the important influences, such as the First and Second World Wars and the development of the National Health Service, which has helped to shape their destiny. [ABSTRACT FROM AUTHOR]

Focuses on the White Paper issued by the British Labor government in 1997 titled 'The New National Health Service: Modern, Dependable.' Review of health care reforms of the previous Conservative government in the context of international reforms; Contents on the White Paper.

Examines the implementation of contracts for health from a series of White Papers on National Health Service and reports on the workshops undertaken from the Health Services Management in England. Issues faced in contracting mental health services; Aims of government policy contained in the White Papers; How far the general aims of government policy can be achieved.

This paper reports on a feasibility study and evaluation of a new type of cultural consultation service (CCS). This multi-component and systemic complex intervention was offered over 18 months to specialist mental health providers in one of the poorest regions of the UK. The service received 900 clinically related contacts and 99 in-depth consultations. Service users who were referred to the CCS had high levels of clinical needs with an average score of 15.9 on the Health of the Nation Outcomes Scale. Overall, Global Assessment of Function scores improved and there were trends for improvements in symptoms. The level of routine care (and by implication associated costs) significantly reduced after CCS intervention, due to a reduction in use of accident and emergency (A&E) services, psychiatrists and community psychiatric nurses (CPNs)/case managers. Cost analysis indicates that savings amounted to £497 per patient. The cost of intervention was no greater than usual care, and may reduce spend per patient over a 3-month follow-up and perhaps longer. More specifically, clinicians felt the cultural consultation service helped to improve the treatment plan (71%), engagement (50%), medication compliance (21%) and earlier discharge (7%). [ABSTRACT FROM AUTHOR]

This paper explores the place that qualified social workers will have in the world of self-directed support and personalisation. Using material from two case studies it argues that continued social work assistance is needed for many service users given the levels of complexity that typify their lives. It also notes that numerous local authorities are reducing the involvement of qualified social workers, citing the need to maximise the levels of choice and control that people have over their lives by reducing external involvement while responding to major financial cuts. It suggests that the consequences of this could be serious for many people, given the chaotic and dangerous nature of their life choices. However, since the allocation of social workers rests with bodies outside of the profession itself it has little direct control of the sorts of practice with which it is engaged. [ABSTRACT FROM AUTHOR]

This paper focuses on patients'/prisoners’ narratives that discuss the National Health Service mental healthcare provided in one Her Majesty's Prison Service establishment. In comparison to the general population, the prevalence of mental illness experienced by the prisoner population is exceedingly high. The prison environment is not conducive to mental health and this custodial clinical setting is not a useful catalyst for mental healthcare for myriad reasons. The pursuit of good mental health for patients in the penal milieu is challenging. For this medical sociology case study, qualitative semi-structured interviews are conducted with male prisoners in a Category B establishment. These participants are also primary or secondary level mental health service users. Analytical discussions concern the clinician–patient relationship and patients’ opinions regarding the mental healthcare received. Debated concepts include: understanding, care, trust, flexibility, cooperation, conversation, relaxation, enjoyment and patient power. Mental healthcare receipt experiences and environments are important. [ABSTRACT FROM AUTHOR]

This paper takes an explicitly political perspective in examining some of the key arguments which General Practice (GP) counsellors, struggling to make sense of working in a milieu that contradicts their value system, are currently needing to address. Beginning with a brief contextualising of the ‘audit culture’ as a ‘hypermodern’ cultural phenomenon, challenges to the author's previous published writings on GP counselling are then invoked to open up key arguments that are confronting GP counsellors in their work. It is argued that there are major difficulties of values-incongruence for any non-Cognitive Behaviour Therapy (CBT) counsellor now working in an NHS GP milieu, and that for practitioners to find an authentic-enough stance for their client work, resistance, subversion and even organised principled non-compliance might be a necessity for practitioners wishing to stay true-enough to their core beliefs and professional identity. The nature of the National Health Service’s (NHS) current attitude to the psychological therapies could mean that practitioners have to make the stark choice between incongruent compliance, values-congruent subversion, or outright rejection of what they are asked to do (with resignation or even redundancy being one possible outcome). A variety of strategies will no doubt be pursued by different practitioners at different times, and the courage that practitioners are able to garner in this paradigmatic struggle for the ‘soul’ of our work can contribute towards a longer-term, much-needed sea-change in the state's attitude to counselling and psychotherapy as modern healing practices. [ABSTRACT FROM AUTHOR]