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Rationale, Aims and Objectives: Six years ago, the Supreme Court judgement in Montgomery v Lanarkshire changed medical law. It introduced a new patient‐based standard of care for the communication of treatment risks and alternatives, rejecting the doctor‐based standard that had long governed all aspects of medical negligence. This is the first systematic review to analyse the literature on Montgomery. Our aim is to appraise and synthesize the literature on Montgomery's impact on medicine and the law and to identify areas for further academic enquiry and implications for professional guidance and training. Methods: Searches were run in Medline, Embase, PsycINFO, Web of Science, Scopus, Westlaw UK, HeinOnline, and LexisNexis. Two reviewers screened papers. Extracted data was analysed and discussed by an interdisciplinary team. PRISMA guidelines were followed. Results: Of the 1134 papers identified, 100 met the inclusion criteria. These papers revealed significant disagreement on four core sets of issues, focusing on Montgomery's impact on: (1) legal and professional duties; (2) medical practice; (3) the patient experience; and (4) litigation. The first set addresses whether the case actually changed doctors' legal and professional duties, the relationship between GMC guidance and medical law, and the boundaries of Montgomery. The second explores whether the decision has incentivized defensive medicine, its resource implications, and doctors' knowledge of it. The third concerns whether and how the decision has promoted patient autonomy and involvement in their own care. The fourth focuses on whether the case has caused an increase in litigation. Conclusions: Despite the abundance of legal and medical literature on Montgomery, many issues remain unresolved. Empirical research is required for many of the questions. Doctrinal analysis informed by medical knowledge is also required to assess whether Montgomery may have unrecognized ramifications—for example, whether it will require the disclosure of risks associated with diagnostic uncertainty, where doctors advise patients without performing procedures. [ABSTRACT FROM AUTHOR]

Introduction: Since non‐directed (altruistic) kidney donors do not stand to benefit from the lengthening and strengthening of a relationship that they intrinsically value, their donations are considered to constitute the most altruistic variety of living kidney donation. Methodology: This paper uses publicly‐available data to assess the expected value that accrues to the donor of altruistic kidney donation. Findings: Compared to healthy non‐donors, living kidney donors experience only marginally increased absolute risks of poor physical health outcomes, and no difference in important psychosocial health outcomes. Crucially, the chance of requiring a kidney donation is only marginally increased by becoming a living kidney donor. In the United Kingdom, previous living kidney donors that subsequently become in need of any organ donation (not only kidneys) themselves are considered priority patients for these donations. They consequently experience shorter waiting times for these organs and reduced exposure to the inherently harmful effects of dialysis therapy (if a kidney donation is required) compared to non‐donors in need of organ donation. As such, while key data points required to compute an accurate and complete expected value calculation are unavailable, it is likely that the additional risk incurred by becoming a living kidney donor is outweighed by the benefit of being considered a priority patient for the donation of any type of organ in the event that this is needed. Conclusion: Accordingly, the expected value of becoming a living kidney donor is likely to be positive, meaning the act of doing so may be considered akin to the taking out of an insurance policy. In the context of non‐directed (altruistic) kidney donation, this may diminish the extent to which such a donation is considered altruistic. [ABSTRACT FROM AUTHOR]

Abstract Clinical audit plays an important role in monitoring the provision of care for patients whatever their condition. Care pathways define the steps and expected course of events in the care of patients with a specific clinical problem over a set time scale. This paper describes a study undertaken in a multisite cancer unit to develop a tool for monitoring the progress of lung cancer patients through a care pathway and auditing key standards within the pathway. Important issues associated with the development of this tool are highlighted. The process of developing this tool involved the following steps: a review of the literature dealing with the management of lung cancer patients; interviews with key personnel in primary, secondary, tertiary and palliative care; development of a paper-based series of forms representing key steps in the patient’s care pathway; 3-month trial of the paper-based tool; analysis of completion rates and interviews with form users to evaluate effectiveness; and recommendations for creating an electronic record using the experience and lessons learned from the paper version. The paper forms developed through this multistage process were found to be acceptable to users and have the potential to provide accurate information at key points for audit throughout the patient’s time within the health-care system for their lung cancer condition. The flexibility of this methodology allows it to be adapted readily to a variety of clinical situations and conditions. [ABSTRACT FROM AUTHOR]

Background: Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non‐consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. Aims: To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. Methods: This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. Results: This review identified 311 relevant primary studies (21 RCTs; 46 non‐controlled experimental or prospective observational studies; 77 cross‐sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross‐country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). Discussion A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non‐consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non‐chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research. [ABSTRACT FROM AUTHOR]

Rationale This study focused on factors that most concern specialist societies when choosing an evidence grading system, such as methodological strengths and weaknesses, applicability and ease of use. The grading systems chosen were the Scottish Intercollegiate Guidelines Network (SIGN), the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the National Service Framework for long-term neurological conditions critical appraisal tool (NSF-LTC). Methodology Twelve assessors, representing typical members of society-based guideline development groups, graded papers and a recommendation using a key question as a guide. Key questions and recommendations were extracted from existing clinical guidelines representing a variety of research fields. Assessors were given 3 months to grade the papers using the grading systems and to complete a semi-structured qualitative questionnaire. The results were independently assessed for emerging themes. Results Assessors felt all three systems had strengths and weaknesses depending on the type of evidence being graded. GRADE was seen as the most complex but rigorous system, while SIGN and NSF were seen as easier and more flexible to use, but less methodologically rigorous. In grading the evidence, 10% of assessors used GRADE incorrectly, 33% used SIGN incorrectly and 75% used NSF-LTC incorrectly. In grading the recommendations, 60% used GRADE incorrectly, 50% used SIGN incorrectly and 50% used NSF-LTC incorrectly. Implications It is recommended that specialist societies consider the type of evidence they will be evaluating and the research experience of the appraisers before selecting a grading system. Additionally, appraisers should have training in appraising and grading evidence using the system to be employed. [ABSTRACT FROM AUTHOR]

The UK National Health Service (NHS) employs a group of 14 separate allied health professions. Prosthetics and orthotics are the smallest of these professions. Although small, orthotics is integral to many clinical care pathways and has shown to provide an essential impact on a range of clinical conditions in the health service priority lists. Previous reports acknowledged the lack of data on the UK prosthetic and orthotic workforce, appointment outcomes and cost and the service users accessing such services and thus the challenges that it poses for effective service delivery. There is still a paucity of relevant data or initiatives to support the service provision. The work within this paper has taken the first step to address this gap, presenting a summary of the information relating to appointments and costs, and provides a discussion on the implications of variations across the NHS orthotic services within England in terms of spend, staffing and skill mix for orthotic services and service users and the need for further data on service users and the UK prosthetic and orthotic workforce. [ABSTRACT FROM AUTHOR]

Rationale Patients concerned about a family history of breast cancer can face difficult decisions about screening, prophylactic surgery and genetic testing. Decision aids can facilitate patient decision making and currently include leaflets and computerized tools. These are largely aimed at the North American market. However, no decision aids concerning familial breast cancer exist in the UK. Methods Focus groups were held with 39 women over 18 years of age referred to a cancer genetics clinic, and who had been given a risk assessment for developing breast cancer. Each focus group examined three existing North American decision aids (1 paper-based and 2 CD-ROMs) and explored what a decision aid in a UK context should look like and the information it should contain. Results There was enthusiasm for the development of decision aids that suit the local context in terms of its health care policy, in paper-based and CD-ROM formats. This paper identifies areas of agreement and disagreement in terms of both content and presentation styles, and also reports some of the suggestions received about where, when and with whom decision aids should be used. Participants suggested that decision aids would be most effective when they allowed a user-selected range of formats. Conclusion There is still significant unmet demand for information and decision support in the context of publicly funded health care. The patient perspective provides a unique insight into issues of design, style and communication. [ABSTRACT FROM AUTHOR]

Rationale aims and objectives Problems exist with Do Not Attempt Cardiopulmonary Resuscitation ( DNACPR) orders: they are often misinterpreted by clinicians to mean that other treatments should be withheld; resuscitation decision discussions are difficult; patients remain inappropriately for resuscitation. We developed an alternative approach. Methods An adapted Delphi method was used. Senior clinicians were interviewed about the strengths and weakness of current practice. Teams who had initiated alternative approaches internationally were contacted. Focus groups were conducted with doctors, nurses and patients to further understand problems with DNACPR orders and establish essential aspects of a new approach. A behavioral economist and management consultant contributed advice. The resulting form was recirculated and further refined. It was: snowballed out to others with specialist expertise (palliative care physicians, intensivists, etc) for further feedback; assessed in simulated clinical encounters before being piloted; further adjusted once in clinical practice. In parallel, a patient information leaflet was developed along with education materials. Results Consensus was achieved that the new approach should: be universal; have discussions and clinical conditions documented first; clarify goals of overall treatment (active treatment or optimal supportive care); contextualize the resuscitation decision among other treatment decisions; have a free text box for 'opting out' of invasive treatments, rather than tick boxes; be green; be limited to one page. Conclusions The Universal Form of Treatment Options was developed iteratively with patients, doctors and nurses as an alternative approach to resuscitation decisions. This paper illustrates a cross-disciplinary approach to developing practical alternatives in health care. [ABSTRACT FROM AUTHOR]

Objectives This paper seeks to further explore the question of how best to monitor and govern innovative clinical procedures in their earliest phase of development. We examine the potential value of proposed governance frameworks, such as the IDEAL model, and examine the functioning of a novel procedures review committee. Methods The paper draws upon 20 qualitative, semi-structured interviews. Nine interviews were conducted with members of a committee that was established as a means of governing innovative procedures within a large National Health Service Foundation Trust hospital in the UK. Eleven interviews were conducted with health providers involved with the development of a variety of novel clinical procedures. Results Prominent themes from the data include the potential willingness of clinicians to engage with regulatory frameworks for innovative procedures, existing ways in which clinicians and others attempt to ensure patient's safety and manage uncertainty in the context of novel procedures, views on the potential benefits and drawbacks of engaging with a review committee for novel procedures, and the pragmatic considerations and potential unintended consequences that are entailed in the implementation of regulatory requirements for the monitoring of innovative procedures. Conclusions The views of committee members and clinical innovators help us to understand the practical issues of implementing governance structures for novel clinical procedures. The data illustrate those factors that must be taken into account if governance is to support innovation rather than act as an inhibiting factor in the development of new clinical procedures. [ABSTRACT FROM AUTHOR]

In this paper we argue that policy calls for personalization or ‘tailored’ services derive a large part of their appeal from the way they ‘fudge together’ different things. Using the recent policy discourses surrounding personalization in the UK NHS as a case study we illustrate the policy ‘work’ that is accomplished by this vagueness and focus in on one important fudge – that between a health service tailored to people's medically defined needs and one tailored to people's wants. Our analysis highlights some of the fundamental philosophical and political questions that need to be addressed before personalization can take shape as a coherent policy option. We also highlight the potential scale of the implications personalization has for the welfare state and argue that such implications warrant greater discussion than is currently being afforded to them. We conclude that philosophical analysis is crucial for guiding the redirection of services implied by personalization discourses. The process of selecting and justifying the way in which the personalization agenda is advanced requires both an analysis of the relationships between needs and wants in human flourishing and an explicit reconsideration of the purpose of the welfare state. [ABSTRACT FROM AUTHOR]

Background and setting This paper outlines the development of a diagnostic tool to help Primary Care general practitioner (GP) Practices diagnose the extent to which they are developing effective techniques for collective learning and if their Practice culture supports innovation. This project is undertaken by the University of St Andrews and NHS Education for Scotland. Methods Based on Learning Organization and Organizational Learning theory, and using a modified Behaviourally Anchored Rating Scale, the Learning Practice Inventory (LPI) identifies attitudes, behaviours, processes, systems and organizational arrangements associated with being a Learning Practice. The LPI is a self-assessment, fixed-choice, survey-feedback tool that surveys all Practice members. Results The survey-feedback tool empowers Practice members to view, assess and prioritize the developments they wish to make collectively to Practice life. The LPI assumes complexity and non-linearity in change processes, used longitudinally it tracks the impact of change on Practice life through time. Practitioners and Practices involved in its development give favourable feedback on the tool, and its potential usefulness. Discussion This contributes to our wider understanding in three main ways: first, it applies the ideas of Learning Organizations and Organizational Learning to health care settings. Second, as a practical advance, the tool assumes complexity, non-linearity and systemic knock-on effects during change in Primary Care. Third, it offers practitioners who work together the opportunity to share knowledge and learning in practical ways helping them to change by themselves and for themselves and their patients. [ABSTRACT FROM AUTHOR]

Background Open and honest discussion between healthcare providers and patients and families affected by error is considered to be a central feature of high quality and safer patient care, evidenced by the implementation of open disclosure policies and guidance internationally. This paper discusses the perceived enablers that UK doctors and nurses report as facilitating the enactment of open disclosure. Methods Semistructured interviews with 13 doctors and 22 nurses from a range of levels and specialities from 5 national health service hospitals and primary care trusts in the UK were conducted and analysed using a framework approach. Results Five themes were identified which appear to capture the factors that are critical in supporting open disclosure: open disclosure as a moral and professional duty, positive past experiences, perceptions of reduced litigation, role models and guidance, and clarity. Conclusion Greater openness in relation to adverse events requires health professionals to recognise candour as a professional and moral duty, exemplified in the behaviour of senior clinicians and that seems more likely to occur in a nonpunitive, learning environment. Recognising incident disclosure as part of ongoing respectful and open communication with patients throughout their care is critical. [ABSTRACT FROM AUTHOR]

Aims and objectives: The aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options (‘UFTO’: an alternative approach that contextualizes the resuscitation decision within an overall treatment plan) on nurses' decision making about a deteriorating patient. Methods: An online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no‐form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures. Results: Reported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no‐form groups (P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments (all P < 0.001). There was no difference between the UFTO and no‐form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups. Conclusion: The presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no‐form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care. [ABSTRACT FROM AUTHOR]

In this article the author discusses the law regarding abortion and referrals to abortion, in response to a paper by Daniel Hill which argues that the Abortion Act 1967 should be extended to referrals for abortions. He raises an objection to Hill's consideration, noting Hill's failure to demonstrate the significant of protecting the right of doctors to conscientious objection to referral to abortion. Two potential responses which may be established from the author's discussed.

Person-centred medicine depends on combining best research evidence with the unique values (including the preferences, concerns, needs and wishes) of individual patients and their families. The paper gives a brief introduction to values-based practice as a new approach to incorporating patients' values into clinical decision making alongside best research evidence as derived from evidence-based practice. The role of values-based practice as a partner to evidence-based practice is illustrated through a series of policy, training and service development initiatives in mental health from the UK Department of Health in London. These initiatives have supported person-centred developments in key areas of mental health practice including, (1) the use of involuntary treatment; and (2) a shared approach of assessment. Early moves are underway to extend values-based practice to other areas of health care beyond mental health. Values-based practice offers a new approach to incorporating patients' unique values into clinical decision making that is complementary to evidence-based practice as a resource for person-centred medicine. [ABSTRACT FROM AUTHOR]

Rationale: Advanced practice physiotherapy roles (Advanced Physiotherapy Practitioners [APPs] and First Contact Physiotherapists [FCPs]) are pivotal in supporting patients to manage their musculoskeletal (MSK) conditions. Having a greater understanding of how decisions are made by these practitioners will inform competency frameworks and improve the provision of patient-centred care., Aim: To evaluate the current knowledge, views and use of shared decision-making in MSK advanced physiotherapy practice in the United Kingdom., Methods: A cross-sectional survey using an online questionnaire was used to collect demographic information, knowledge, views and self-reported use of shared decision-making (SDM) of APPs and FCPs who work with adults with MSK disorders in the United Kingdom., Results: Responses from 49 participants (25 APPs and 24 FCPs) were included in the study. In total, 80% of participants had received SDM training and overall high levels of knowledge were shown. Only 12% of participants used a communication model to facilitate SDM. In total, 80% of participants reported making decisions together with the patient either always or most of the time. FCPs favoured a more patient-led approach to decision-making compared to APPs who favoured collaborative decision-making. The most commonly reported barriers to SDM included lack of time, lack of patient education resources, lack of access to patient decision aids and treatment pathway restrictions., Conclusions: The responses in this study showed that overall APPs and FCPs have good knowledge of SDM and report routine use of collaborative and patient-led decision-making approaches., (© 2024 The Author(s). Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Rationale, aims and objectives Differences in the performance of medical care may be due to variation in the introduction and diffusion of medical innovations. The objective of this paper is to compare seven European countries ( United Kingdom, the Netherlands, West Germany, France, Spain, Estonia and Sweden) with regard to the year of introduction of six specific pharmaceutical innovations (antiretroviral drugs, cimetidine, tamoxifen, cisplatin, oxalaplatin and cyclosporin) that may have had important population health impacts. Methods We collected information on introduction and further diffusion of drugs using searches in the national and international literature, and questionnaires to national informants. We combined various sources of information, both official years of registration and other indicators of introduction (clinical trials, guidelines, evaluation reports, sales statistics). Results and conclusions The total length of the period between first and last introduction varied between 8 years for antiretroviral drugs and 22 years for cisplatin. Introduction in Estonia was generally delayed until the 1990s. The average time lags were smallest in France (2.2 years), United Kingdom (2.8 years) and the Netherlands (3.5 years). Similar rank orders were seen for year of registration suggesting that introduction lags are not only explained by differences in the process of registration. We discuss possible reasons for these between-country differences and implications for the evaluation of medical care. [ABSTRACT FROM AUTHOR]

The recent Mental Capacity Act (2005) sets out a test for assessing a person's capacity to make treatment choices. In some cases, particularly in psychiatry, it is unclear how the criteria ought to be interpreted and applied by clinicians. In this paper, I argue that this uncertainty arises because the concept of capacity employed in the Act, and the diagnostic tools developed to assist its assessment, overlook the inherent normativity of judgements made about whether a person is using or weighing information in the decision-making process. Patients may fail on this criterion to the extent that they do not appear to be handling the information given in an appropriate way, on account of a mental impairment disrupting the way the decision process ought to proceed. Using case law and clinical examples, I describe some of the normative dimensions along which judgements of incapacity can be made, namely epistemic, evaluative and affective dimensions. Such judgements are complex and the normative standards by which a clinician may determine capacity cannot be reduced to a set of criteria. Rather, in recognizing this normativity, clinicians may better understand how clinical judgements are structured and what kinds of assumption may inform their assessment. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Patient-centred care has been a central part of US and UK health policy for over a decade, but, despite its importance, the policy literature often fails to provide an adequate theoretical justification for why and how we should value it. This omission is problematic because it renders the status, content and appropriate evaluation of patient-centredness unclear. In this paper we aim to examine two different accounts of patient-centred care. Method We draw upon methods of conceptual and ethical analysis. Results We argue that neither of the two accounts of patient-centred care identified appropriately grounds patient-centredness because neither of them takes into account the inherently moral nature of terms such as 'respect' and 'dignity', terms that are central to discussions of patient-centred care. Conclusions We suggest that clinical ethics can help to provide a theoretical justification for patient-centred care, and that clinical ethical practices can further patient-centred initiatives through ethics consultation, education and policy development and review. [ABSTRACT FROM AUTHOR]

High-grade glioma profoundly affects patients and their families. The best ongoing care for patients completing radical treatment is uncertain. To address this issue a UK-wide audit surveying the follow-up practices of multidisciplinary cancer teams was conducted. An online survey package was used with a paper version available. Of 102 clinicians approached 86 replied, a response rate of 84%. Three-monthly outpatient department appointments led by an oncologist and a specialist nurse were the norm, but more controversially, some centres conduct joint clinics with the whole neurosurgical/oncology team present or available. Nurse-led telephone follow-up in place of hospital visits is uncommon. Regular scanning is conducted despite the clinical benefits being contentious. Access to a range of allied services providing supportive care is considered, but the actual levels of need and the efficiency with which they are delivered require further investigation. The picture of UK follow-up practices revealed by this survey demonstrates that research is now needed to determine what preferences patients and families have for follow-up and their satisfaction with these. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Stroke care has been at the forefront of the drive to deliver health care by teamworking in the UK. Teamworking is the subject of ongoing audit of stroke provision with measures such as a weekly team meeting being used to evaluate services. A qualitative study was recently undertaken to explore these evaluations and to gain further understanding of the processes underlying teamworking practice. Methods Three case study sites across the stroke care pathway were investigated using data collection methods of fieldwork observation, interviews and visual imagery. The data were coded and analysed in an inductive process in parallel to the data gathering. Results It was found that teamworking practice was affected by organizational conditions, such as location of staff, time constraints, management structures and team contact. Other important aspects of teamworking related to the formation of subteams, decision-making processes, leadership, identification of goals, and training in teamworking. Conclusions It is suggested that additional measures of team functioning are required. This paper highlights the importance of the organizational background with the need to consider team size, accountability and changing group membership. It discusses the decision-making systems and the need to more fully consider the role and purpose of team meetings. [ABSTRACT FROM AUTHOR]

The article offers information on the shared decision making (SDM) and person centered care (PCC). Topics include the meaningful implementation of SDM presents not only practical but conceptual challenges; SDM requires understanding factors affecting patient decision making; and the cognitive and emotional skills being needed to implement SDM.

Rationale, aims and objectives The publication of health outcome data – rather than merely the measurement and collection – is being given increasing consideration. Publication reflects society's increasing emphasis on a general ‘right to know’, as well as being a means of informing consumer choice. In theory, publication may help to promote public trust, support patient choice, and stimulate action to improve the quality of care whilst controlling costs. Methods Drawing on a literature review, this paper overviews the strategies employed in the UK and US to publish outcome data. The focus is on outcomes, and certain related process measures, that measure the performance of hospitals or surgeons. Results and conclusions Presenting the limited evidence that exists, we review the potential beneficial and harmful effects of publishing hospital outcome data. We also consider the risks of making incorrect inferences based on these data and the potential for dysfunctional consequences. Recognizing that the public largely mistrusts currently published health outcome data, we offer some recommendations for the future direction of strategies for publication. [ABSTRACT FROM AUTHOR]

There have been many changes in the practice of medicine in the UK in the recent past, including major changes in training and trainees’ hours, treatment options and patient expectations. These, in combination with a need for better accountability and improved continuing medical education, have increased the demands on senior doctors, and made apparent the need for increased medical resource. There would seem to be four areas through which this is being addressed – increased production of doctors; changes in medical training; changes in medical practice, and retention of seniors in post. This paper examines some of the perceived advantages and potential disadvantages of these approaches. It concludes that if the health service is to have a viable long-term future, its survival in the short term depends on maintaining within the service the skills of those seniors who have borne the brunt of recent change. [ABSTRACT FROM AUTHOR]

SummaryThe medical care of people with epilepsy has often been described as being poor, although objective markers for the quality of epilepsy care are lacking. This paper describes the results of using a simple quality marker, appropriate measuring of serum anticonvulsant levels, in assessing the quality of epilepsy care. The checking of serum phenytoin levels in certain clinical circumstances is advocated, whereas the checking of serum sodium valproate levels is not generally supported. A total of 1254 people with epilepsy in the community had their medical records examined for evidence of checking of anticonvulsant levels and 1204 of these individuals completed questionnaires about their epilepsy and its treatment. Of those on phenytoin, only 26% to 47% had phenytoin levels checked appropriately; 23% of patients on sodium valproate were inappropriately having their serum levels checked. The only clinical or organizational factor that predicted whether checking of serum phenytoin levels was performed was whether or not patients reported three common phenytoin side-effects but this still showed a small effect size (odds ratio 2.4). [ABSTRACT FROM AUTHOR]

Over the last 10 years a series of issues have raised concern over the state of British cancer services. The UK has some of the worst survival rates in the world and annual expenditure per capita is inferior to that of many countries with smaller GDPs. This paper is the first tranche of evidence from Professor Ferlie's Group on UK cancer services, following a survey conducted over 2 years ago. A similar, more intensive, but less extensive survey conducted by the Audit Commission at the same time confirms Ferlie's findings. It appears that implementation of the ground-breaking Calman-Hine Report (1995), recommending reorganization of cancer services, has been patchy, incoherent and incomplete. [ABSTRACT FROM AUTHOR]

Background Child psychoanalytic psychotherapy has been criticized for its reluctance to embrace evidence-based practice. This study aims to explore the historical narrative of a sample of child psychoanalytic psychotherapists about progress in developing the evidence base. Methods Fourteen psychotherapists were interviewed and the transcripts analysed for common themes about evidence-based practice. Results Child psychoanalytic psychotherapists were generally positive about developing evidence-based practice but had reservations about the narrowness of hierarchies used by commissioners to assess evidence. Conclusion The child psychoanalytical psychotherapists interviewed for this study recognized the need to promote evidence-based practice, in particular, to inform commissioners of Child Mental Health Services. [ABSTRACT FROM AUTHOR]

In this article, the author discusses the revalidation issue in the field of medical care. The author focuses on the revalidation of the care provided to several patients as well as health care. The author notes how general practitioners have implemented best practice on their chosen career in Great Britain. Furthermore, the revalidation's relevance to both physicians and patients, is also noted.

Rationale, Aims and Objectives: Sharing aspects of the traditional medical record with patients has been successful in primary and antenatal care, but has not been investigated in the UK inpatient setting. Our aim was to evaluate the impact on patient and clinician experience of providing patients with a written lay summary of their care‐plan in the acute care setting. Method: We carried out a qualitative interview study on two acute medicine wards in an NHS University Teaching Hospital for a 4‐week period in 2019. A summary record, designed in response to suggestions from doctors and patients from a previous study, was distributed to patients on the first ward round after admission. Eligible participants included all doctors and nurses working on and all patients and their families attending the acute medical units; patients were excluded if they lacked capacity to consent or were under 18. We interviewed 20 patients, 10 relatives, 10 doctors and 7 nurses. Results: Patients felt that the summary improved their ability to remember details about their care so they could more accurately and easily update their relatives. They did not feel that the summary induced anxiety. Patient‐doctor communication was improved: patients felt empowered to ask more questions and doctors felt that it solidified their plan and encouraged them to avoid medical jargon. Most patients felt the summary included the 'right' amount of information. Healthcare professionals were more concerned about the risk of breaching confidentiality than patients. Doctors felt that providing summaries was time‐consuming; there were differing opinions about whether this was a worthwhile investment of time. Clinicians recognized that the traditional medical record has many roles. Conclusions: A summary record could empower patients and improve patient‐doctor communication but would require additional clinician and administrative time. [ABSTRACT FROM AUTHOR]

Evaluation does not generally command a high priority during either the design or the subsequent dissemination of new educational interventions in medical education (Rolfe 1997). New courses and programs are often initiated in the firm and sometimes arrogant belief that all or most of the objectives will be achieved. The publicity associated with the introduction of a new course or curriculum is rarely matched by an adequate assessment of either the costs or effects of the educational innovation (Gonella 1982). Within the undergraduate institutions, spared the cold eye of peer review, courses and curricula rumble on. Students graduate, become doctors and appear to perform well enough. In recent years regulatory bodies such as the General Medical Council of the United Kingdom (GMC) have questioned the traditional Flexnerian medical school curricula (Towle 1998b) and suggested radical changes to both content and structure (GMC Tomorrow’s Doctors 1993). This has led to widescale changes in medical school curricula with the introduction of integration between the basic and clinical sciences and elements of choice around a core curriculum. There is little evidence in the literature to suggest that these changes have been accompanied by associated evaluative measures. Thus there appears to have been an almost unquestioning acceptance of the GMC recommendations, with few if any assessments of the effects of these changes on the individual medical schools or their students. It would be informative to establish whether undergraduates who are experiencing the GMC initiated curricular changes differ from their predecessors in their ability to apply their knowledge to clinical problems. If there are differences, it is only by formal evaluation that we can determine which aspects of the curriculum and its delivery were foundational to these differences? I would like to consider, in this editorial, why educational evaluation in medicine should happen and yet in so many... [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Healthcare systems worldwide devote significant resources towards collecting data to support care quality assurance and improvement. In the United Kingdom, National Clinical Audits are intended to contribute to these objectives by providing public reports of data on healthcare treatment and outcomes, but their potential for quality improvement in particular is not realized fully among healthcare providers. Here, we aim to explore this outcome from the perspective of hospital boards and their quality committees: an under‐studied area, given the emphasis in previous research on the audits' use by clinical teams. Methods: We carried out semi‐structured, qualitative interviews with 54 staff in different clinical and management settings in five English National Health Service hospitals about their use of NCA data, and the circumstances that supported or constrained such use. We used Framework Analysis to identify themes within their responses. Results: We found that members and officers of hospitals' governing bodies perceived an imbalance between the benefits to their institutions from National Clinical Audits and the substantial resources consumed by participating in them. This led some to question the audits' legitimacy, which could limit scope for improvements based on audit data, proposed by clinical teams. Conclusions: Measures to enhance the audits' perceived legitimacy could help address these limitations. These include audit suppliers moving from an emphasis on cumulative, retrospective reports to real‐time reporting, clearly presenting the "headline" outcomes important to institutional bodies and staff. Measures may also include further negotiation between hospitals, suppliers and their commissioners about the nature and volume of data the latter are expected to collect; wider use by hospitals of routine clinical data to populate audit data fields; and further development of interactive digital technologies to help staff explore and report audit data in meaningful ways. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Maternity training is a critical global issue. In the United Kingdom (UK), the need for safer care and patient safety is emphasized through NHS policy. Health Education England (HEE) recommends that training should support a culture of continuous learning and improvement, particularly in the area of reducing the rates of stillbirths, neonatal and maternity deaths, and other adverse outcomes, such as intrapartum brain injuries. Training has been shown to play a crucial role in improving quality of care and reducing maternal and perinatal mortality and morbidity. This evaluation was undertaken to determine both the immediate and sustained impact of multiprofessional training in cardiotocograph (CTG) interpretation and community‐based simulation training in obstetric emergencies: childbirth emergencies in the community (CEC). The impact was measured in terms of practitioner knowledge, confidence, and empowerment immediately pretraining and posttraining and at 12 weeks following training. Methods: A longitudinal mixed methods design was used. Attendees to maternity training sessions on cardiotocograph interpretation and management of childbirth emergencies in the community provided the sample. Quantitative data were collected using questionnaires to assess knowledge, confidence, and empowerment. Qualitative data were collected using open‐ended questions embedded in the questionnaires. Quantitative data were analysed using within‐subject t test to compare differences in the dependent variable measures. Qualitative data analysis was guided by Braun and Clarke (2013) method thematic analysis. Results: The combined qualitative and quantitative results lucidly highlight that training positively impacts upon knowledge, confidence, and empowerment, an impact which is observed across three time points. Conclusions: Training in CTG and CEC is effective in improving knowledge, confidence, and empowerment across all groups. Furthermore, the provision of training packages in these subject areas facilitates improvements in the longer term. [ABSTRACT FROM AUTHOR]

There has been a recent proposal by Gergel and Owen for introduction of legally enforceable self-binding directives for persons with bipolar affective disorder in the United Kingdom. The model is rooted in presence or absence of decision-making capacity, and the notion of capacity used is an expansion of the usual notion of capacity, in that it is individualized and diachronic. In this article, I argue that an individualized notion of capacity either lacks a coherent foundation or exposes itself to a situation where epistemological error results in a double standard or unjustified enforcement of the directive. I also raise concern that the diachronic notion of capacity leads to an authenticity type account, which fails to incorporate differences in individual prognosis. I then present a rough sketch of an alternative account, more in keeping with current mental health legislation, which uses an individualized notion of 'risk to self' to justify self-binding directives in bipolar disorder. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care. Methods All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web-based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses. Results Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1-33; SD = 7.13). Seven hundred sixty-seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0-34; SD = 8.0). Conclusions The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System-wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Despite the widespread inclusion of consultation skills in undergraduate healthcare curricula, patient-doctor interactions are often an imparting of evidence or information rather than an exchange. Evidence-based practice may be further enhanced by increasing explicit understanding of decision-making processes used by healthcare professionals and patients. This exploratory investigation evaluated the impact of an educational intervention on understanding of decision-making processes and practice. The effect of session schedule was assessed to inform the future delivery strategy of such approaches. Methods Three groups of primary care health professionals (n = 85) completed questionnaires using Likert scales to assess strength of agreement with decision-making statements exploring four themes - Theory, Applied Theory, Practice and Joint Practice - preintervention and post-intervention. Responses were analysed, firstly to assess the impact of the intervention on understanding of decision-making processes and practice across all participants and then by group to determine the effect of session schedules on outcome measures. Results Overall agreement with the decision-making statements significantly increased after the learning set (Mean = -0.162, SD = 0.355); t(64) = -3.666, p < 0.001). Multivariate analysis on effect of session schedule only found significant interactions for the theme 'Joint Practice' with group (p < 0.025) and 3-way interaction of Group and Main role. (p < 0.048). No consistent positive impact of longer session schedule was found. Conclusion Participation in the learning sessions significantly improved self-reported understanding of decision-making processes and application to clinical practice. The extended learning sessions did not provide additional benefits over and above 2 half days or 1 whole day learning sessions. [ABSTRACT FROM AUTHOR]

Objectives To design and evaluate the effectiveness of a pre-notification leaflet about research to increase recruitment to a randomized controlled trial (RCT). Methods A methodological, two-arm, RCT was conducted, embedded within an existing cohort RCT (REFORM). Participants were randomized for the embedded trial, using a 1:2 ratio (intervention : control) before being randomized for REFORM. Controls received a trial recruitment pack. The intervention group received an additional pre-notification leaflet 2-3 weeks before the recruitment pack. Primary and secondary analyses were conducted using relative risk, the Cox proportional hazards model and incremental cost-effectiveness ratios. Results Of the 1436 intervention group participants, 73 (5.1%) were randomized into the REFORM trial compared with 126 (4.4%) of the 2878 control group participants. The associated relative risk (1.16) was not statistically significant [95% confidence interval (CI) 0.88-1.56]. Return rate was not significantly increased (relative risk 1.10, 95% CI 0.92-1.28) nor time to return decreased (hazard ratio: 1.11, 95% CI 0.93-1.33). Incremental cost-effectiveness ratios indicated the intervention may be cost-effective if the true estimate of effect was close to the upper bound of the associated 95% CI. Conclusion Pre-notification for potential trial participants demonstrated a small difference to randomization (0.7% difference) and return rates (1.1% difference) in favour of the intervention. Results should however be interpreted with caution as CIs for these estimates cross the point of no effect. Nevertheless, this research enhances existing evidence for pre-notification to increase recruitment rates, with further development and assessment of this potentially cost-effective intervention being recommended. [ABSTRACT FROM AUTHOR]

Objectives Few studies have investigated the quality of pre-hospital care by ethnicity. We aimed to investigate ethnic differences in pre-hospital ambulance care of patients with suspected cardiac pain. Methods We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with suspected cardiac pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data, clinical measurements, drugs administered and outcomes, such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-White with White patients. Results There were 7046 patients with suspected cardiac pain, with 4825 who had ethnicity recorded including 4661 (96.6%) White and 164 (3.4%) non-White. After correcting for age, sex, socio-economic status and whether transported to hospital, non-White patients were significantly more likely to have temperature [odds ratio (OR) 2.96, P = 0.007], blood glucose (OR 3.95, P = 0.003), respiratory rate (OR 4.94, P = 0.03) and oxygen saturation (OR 2.43, P = 0.006) recorded. Non-White patients were significantly less likely to be transported to hospital (OR 0.43, P = 0.03). Conclusion There were significant differences in pre-hospital ambulance care for non-White compared with White patients with suspected cardiac pain. These differences could be due to differences in clinical condition or case-mix, language and cultural barriers, limited understanding of appropriate use of health care services, recording bias or true differences in provider management. Further analysis should involve larger and more complete data sets to explore ethnic differences in greater detail. [ABSTRACT FROM AUTHOR]

The primary aims are to consider whether a range of paternalistic medical interventions can be justified in the treatment of factitious disorder ( FD) and to show that the particularities of FD and its management make it an ideal phenomenon to highlight the difficulties of balancing respect for self-determination, responsibility and duty of care in psychiatry. FD is usually classified as a mental disorder involving deliberate and hidden feigning or inducement of illness, in order to achieve patient status. Both the nature of the disorder and the approach to treatment are controversial and under-researched. It is argued that FD should be classified as a mental disorder; may well expose the patient to extreme risk; can warrant paternalistic interventions, in order to fulfil duty of care. Moreover, treatment of FD is inherently paternalistic and therefore raises interesting questions about justifications and type of paternalistic interventions in psychiatry both for FD and in general. A brief account of key questions concerning psychiatry and paternalism is followed by some case histories of FD, the clinical dilemmas posed and the question of how this disorder might warrant paternalistic interventions. In order to answer this question, two things are considered: the legitimacy and character of FD as a mental disorder; possible frameworks for and types of paternalistic interventions. To conclude, it is argued that there are no compelling reasons for rejecting the use of paternalistic interventions for FD, but that further investigation of FD and type and frameworks for psychiatric paternalism, in relation to FD and other mental disorders, are urgently needed. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The management of rheumatoid arthritis ( RA) usually entails regular hospital reviews with a specialist often when the patient is well rather than during a period of exacerbation. An alternative approach where patients initiate appointments when they need them can improve patient satisfaction and resource use whilst being safe. This service evaluation reports a system-wide implementation of a patient-initiated review appointment system called Direct Access ( DA) for people with RA. The aim was to establish the impact on patient satisfaction of the new system versus usual care as well as evaluate the implementation processes. Methods As all patients could not start on the new system at once, in order to manage the implementation, patients were randomly allocated to DA or to usual care. Instead of regular follow-up appointments, DA comprised an education session and access to a nurse-led telephone advice line where appointments could be accessed within two weeks. Usual care comprised routine follow-ups with the specialist. Data were collected on patient satisfaction, service use and outcomes of any contact to the advice line. Results Three hundred and eleven patients with RA were assessed as being suitable for DA. In terms of patient satisfaction, between-group differences were found in favour of DA for accessibility and convenience, ease of contacting the nurse and overall satisfaction with the service. Self-reported visits to the general practitioner were also significantly lower. DA resulted in a greater number of telephone contacts (incidence rate ratio = 1.69; 95% confidence interval 1.07 to 2.68). Hospital costs of the two different service models were similar. Mean waiting time for an appointment was 10.8 days Conclusion This service evaluation found that DA could be implemented and it demonstrated patient benefit in a real-world setting. Further research establishing the broader cost-consequences across the whole patient pathway would add to our findings. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Smartphone and mobile application technology have in recent years furthered the development of novel learning and assessment resources. ' MBChB Mobile' is a pioneering mobile learning ( M- Learning) programme at University of Leeds, United Kingdom and provides all senior medical students with iPhone handsets complete with academic applications, assessment software and a virtual reflective environment. This study aimed to evaluate the impact of MBChB Mobile on student learning. Methods Ethical approval was granted to invite fourth and fifth year medical students to participate in a semi-quantitative questionnaire: data were collected anonymously with informed consent and analysed where appropriate using chi-squared test of association. Qualitative data generated through focus group participation were subjected to both content and thematic analysis. Results A total of 278 of 519 (53.6%) invited participants responded. Overall, 72.6% of students agreed that MBChB Mobile enhanced their learning experience; however, this was significantly related to overall usage ( P < 0.001) and self-reported mobile technology proficiency ( P < 0.001). Qualitative data revealed barriers to efficacy including technical software issues, non-transferability to different mobile devices, and perceived patient acceptability. Conclusions As one of the largest evaluative and only quantitative study of smartphone-assisted M- Learning in undergraduate medical education, MBChB Mobile suggests that smartphone and application technology enhances students' learning experience. Barriers to implementation may be addressed through the provision of tailored learning resources, along with user-defined support systems, and appropriate means of ensuring acceptability to patients. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives A prototype diagnostic clinical decision support system ( CDSS) was developed to assist primary care clinicians (general practitioners) in clinical decision making, aimed at reducing diagnostic errors. The prototype CDSS showed some promise with high levels of validity and reliability; however, issues regarding the underlying Bayesian belief network ( BBN), small sample size and use of radiological imaging as a gold standard measure were highlighted that required further investigation before considering clinical testing. Methods The prototype CDSS was reviewed and updated based on computer science literature and expert (orthopaedic consultant) opinion. The updated CDSS was tested by comparing its diagnostic outcome against the diagnosis of 93 case studies as determined by expert opinion combined with arthroscopy findings or radiological imaging. Results The updated CDSS showed significant high levels of sensitivity (91%), specificity (98%), positive likelihood ratio (53.12) and negative likelihood ratio (0.08) with a kappa value of 0.88 to a confidence level of 99% compared with expert diagnosis combined with arthroscopy findings or radiological imaging. Conclusions The results suggest that the updated CDSS has addressed the issues highlighted from the initial research while maintaining high levels of validity and reliability. The updated CDSS is now ready for clinical testing. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives In the context of an ageing population, increasing numbers of older people with long-term conditions are presenting to secondary health care facilities in the United Kingdom having experienced a fall or fall-related injury. Despite such observations, falls and long-term conditions have traditionally been regarded as entirely separate entities. The purpose of this study was to explore the process of behaviour change in a small sample of older people with the fall-associated chronic liver disease primary biliary cirrhosis ( PBC) receiving either a standard or an enhanced programme of strength and balance training ( SBT). Methods A qualitatively driven mixed-methods approach was employed that juxtaposed semi-structured interviews with graphical representations of patient-reported outcome measures collected during the course of an experimental case series in nine older people with the fall-associated chronic liver disease PBC. Results Participants receiving both the standard and enhanced intervention completed the programme of SBT as instructed throughout the course of the case series. However, only the enhanced intervention, which focused on self-determination and self-management support, was associated with continued active participation on completion of the programme. Conclusions Longer, but not necessarily more intensive, periods of clinical intervention are necessary to support individuals at risk of falling to move through the incremental stages of behaviour change. Effective self-management support should focus on the development of a wide range of strategies and behaviours to empower older people with long-term conditions develop an ongoing active commitment to SBT. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To find consensus, or lack thereof, on the impact of reducing alcohol consumption on prognosis and the risk of hospital admissions for a number of alcohol-attributable disorders. Methods A modified two-round Delphi survey utilizing web-based questionnaires to collect quantitative and qualitative data was used. Alcohol treatment experts from cardiology, emergency medicine, gastroenterology and oncology in the United Kingdom were invited to participate. The main outcomes were median impact ratings (on a scale of 1-9) and consensus (unanimous, strong, moderate, weak or no consensus). Results Of 192 experts invited to participate, 59 completed first questionnaires. The overall retention rate to the second questionnaires was about 51% (30/59). There was strong support that reducing alcohol consumption could result in improvement in prognosis for gastroenterology and emergency medicine patients; but uncertainty on the benefits for cardiology and oncology patients. Overall, the responses from the expert panel did not reflect the assumption that reducing alcohol consumption would result in benefits on hospital admissions for any of the specialties. The specialists viewed the severity of disorders as important when considering the impact of reducing alcohol consumption. Conclusions The highest impact of treatment for problem drinking in hospitals is considered to be for alcohol-related disorders associated with gastroenterology and emergency medicine. At policy level, if targeted screening for alcohol problems by presenting disease or condition is the strategy of choice, it would be logical to implement screening and easily accessible interventions or addiction specialists within these areas where alcohol treatment is considered as having a high impact. [ABSTRACT FROM AUTHOR]

Introduction Significant event analysis (SEA) is now well established in UK primary care. Previously, considerable variation has been reported in the knowledge, skills and attitudes of general practitioners undertaking SEA. Little is known about the wider team's understanding, participation or perceptions. We therefore aimed to determine the awareness, degree of analysis and perceived risk of recurrence of a recent significant event, types of discussion forums, staff groups' participation and perceived barriers. Comparisons were made with a 2003 survey and significant changes described. Method A postal questionnaire survey was undertaken of a random selection of general practice team members in National Health Service Greater Glasgow in 2008/9. Results In total, 375/711 respondents (53%) from 111 practices participated. The vast majority was aware of a recent significant event, 29% reported not implementing a change and 23% perceived the risk of recurrence as moderate to high. Administrative and community-based staff were infrequently involved in meetings. Dedicated significant event meetings remain uncommon ( P = 0.06). Perceptions improved since 2003, but lack of time remained a concern. Discussion This survey was the first known attempt to include all members of the primary care team while studying SEA. Awareness and analysis levels were high, but only lead to sustainable improvement of care quality and clinical safety if teams implement change. Greater use should be made of dedicated SEA meetings and participation of all staff groups increased to gain full benefits. Lack of time can be managed pragmatically by prioritizing events based on their perceived severity, potential for change and potential team involvement. [ABSTRACT FROM AUTHOR]

Background Although an increasing number of decision support interventions for patients (including decision aids) are produced, few make explicit use of theory. We argue the importance of using theory to guide design. The aim of this work was to address this theory-practice gap and to examine how a range of selected decision-making theories could inform the design and evaluation of decision support interventions. Methods We reviewed the decision-making literature and selected relevant theories. We assessed their key principles, theoretical pathways and predictions in order to determine how they could inform the design of two core components of decision support interventions, namely, information and deliberation components and to specify theory-based outcome measures. Results Eight theories were selected: (1) the expected utility theory; (2) the conflict model of decision making; (3) prospect theory; (4) fuzzy-trace theory; (5) the differentiation and consolidation theory; (6) the ecological rationality theory; (7) the rational-emotional model of decision avoidance; and finally, (8) the Attend, React, Explain, Adapt model of affective forecasting. Some theories have strong relevance to the information design (e.g. prospect theory); some are more relevant to deliberation processes (conflict theory, differentiation theory and ecological validity). None of the theories in isolation was sufficient to inform the design of all the necessary components of decision support interventions. It was also clear that most work in theory-building has focused on explaining or describing how humans think rather than on how tools could be designed to help humans make good decisions. It is not surprising therefore that a large theory-practice gap exists as we consider decision support for patients. There was no relevant theory that integrated all the necessary contributions to the task of making good decisions in collaborative interactions. Discussion Initiatives such as the International Patient Decision Aids Standards Collaboration influence standards for the design of decision support interventions. However, this analysis points to the need to undertake more work in providing theoretical foundations for these interventions. [ABSTRACT FROM AUTHOR]

Recent UK policy has promoted routine monitoring of the performance of cancer services. Clinical databases are one method of collecting the detailed data required for clinically relevant analyses and of supplementing that collected by cancer registries. To describe characteristics of patients, their treatment and surgical care recorded in the North Thames Prospective Audit of Colorectal Cancer database compared with the Thames Cancer Registry database between 1999 and 2004. We defined the geographical area served by the prospective audit and extracted a registry dataset for the same area. We compared the numbers, age, sex, cancer site and staging of patients in each database. The proportions recorded as receiving surgery, radiotherapy and chemotherapy were compared over time, and clinical standards recorded for preventing post-operative complications and for specialist care were determined from the clinical database. Clinical and registry databases differed in case mix. The clinical database began to capture data on a larger number and wider range of patients over time, and generally included more complete staging data. Treatment trends differed between the databases, with the registry data showing lower proportions undergoing surgery and a slight increase in rectal cancer surgery over time. There was a suggestion that a higher proportion of men received radiotherapy and chemotherapy than women. Recording of surgical standards in the clinical database was generally poor, although decreased leak and infection rates and post-operative mortality were suggested in the initial years of the audit. The clinical database contributed some additional information on patient characteristics and the performance of services, but variable data quality and completeness prevented many planned analyses. Collecting additional data requires funded structures and quality assurance systems and such effort should focus on the data required to answer the most pressing clinical questions. [ABSTRACT FROM AUTHOR]

Leadership and innovation are currently seen as essential elements for the development and maintenance of high-quality care. Little is known about the relationship between leadership and culture of innovation and the extent to which quality improvement methods are used in general practice. This study aimed to assess the relationship between leadership behaviour, culture of innovation and adoption of quality improvement methods in general practice. Self-administered postal questionnaires were sent to general practitioner quality improvement leads in one county in the UK between June and December 2007. The questionnaire consisted of background information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for culture of innovation and questions on current use of quality improvement tools and techniques. Sixty-three completed questionnaires (62%) were returned. Leadership behaviours were not commonly reported. Most practices reported a positive culture of innovation, featuring relationship most strongly, followed by targets and information but rated lower on other dimensions of rewards, risk and resources. There was a significant positive correlation between leadership behaviour and the culture of innovation ( r = 0.57; P < 0.001). Apart from clinical audit and significant event analysis, quality improvement methods were not adopted by most participating practices. Leadership behaviours were infrequently reported and this was associated with a limited culture of innovation in participating general practices. There was little use of quality improvement methods beyond clinical and significant event audit. Practices need support to enhance leadership skills, encourage innovation and develop quality improvement skills if improvements in health care are to accelerate. [ABSTRACT FROM AUTHOR]

Little is documented about contemporary management of speech and swallowing disorders associated with paediatric acquired brain injury (ABI). It is therefore challenging for clinicians in this field to benchmark their clinical management against current evidence or practices undertaken in other centres. To address this issue, we aimed to provide much-needed baseline data on speech and language pathology management of speech and swallowing disorders associated with childhood ABI. Key objectives were to: (i) determine whether clinicians use formalized referral criteria, clinical guidelines, protocols or care pathways; and (ii) to document the specific assessment and treatment approaches used. Speech and language pathology managers and clinicians at 31 major paediatric rehabilitation centres across Australia, New Zealand, the UK and Ireland were invited to participate in an online survey. Fifty-one speech and language pathologists responded representing 26 centres (84% response rate). Routine referrals of ABI patients to speech and language pathology occurred relatively infrequently in these centres (12%). Centres utilized assessment protocols (23%) and guidelines (35%) more frequently than treatment guidelines (8%). Multidisciplinary care pathways were applied by 31%. Most centres used adult-based motor speech assessments and informal ('in-house developed') swallowing assessment tools. The limited use of referral criteria, protocols, care pathways and guidelines invites the possibility of unequal care, and less than optimal outcomes. Reliance on adult-based or in-house assessments is inappropriate, yet frequently a necessity due to an absence of paediatric-specific tools in this field. Further research is required in parallel with the formation of consensus groups to support the development of: (i) paediatric-specific assessment tools and management approaches; and (ii) clinical protocols and guidelines. [ABSTRACT FROM AUTHOR]

The growing interest in patient-focused health care in the National Health System (NHS), especially in the wake of high-profile failures in clinical practice, has underlined the need to involve patients in the design and evaluation of organizational change management programmes at the local level. This includes an evaluation of the relevance of culture and how culture might be assessed and managed in the delivery of high-quality and safe care. The purpose of this study is to compare and contrast the perspectives of health care professionals and patient representatives on purposeful attempts to manage culture change in the English NHS. We used the mixed approach, but with more quantitative than qualitative data. A postal questionnaire survey of clinical governance leads and patient representatives from 276 NHS trusts was followed up with a focus group discussion of eight of the survey participants and semi-structured interviews with 18, including health care professionals and patient representatives from various organizations. We used to analyse the survey data and Atlas.ti to analyse the qualitative data. Both clinical governance leads and patient representatives considered culture management and change to be integral to quality and safety improvement efforts. However, clinical governance leads were more positive than patient representatives about anticipated results from ongoing efforts to manage culture change at the local level. Further, in spite of general agreement on various attributes for culture assessment efforts, there was a striking difference in the level of importance respondents attached to blame free (more important to clinical governance managers) and customization (more important to patient representatives). [ABSTRACT FROM AUTHOR]

To investigate perceived factors relating to the reliable application of four clinical care practices targeting ventilator-associated pneumonias, in the context of a patient safety improvement initiative called the Safer Patients Initiative (SPI). Qualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programme's critical care work stream during its pilot phase. The interviews had a focus on perceived aspects pertaining to the reliable implementation of the four clinical practices, promoted by the Institute for Healthcare Improvement as the 'ventilator care bundle'. Thematic analysis of the verbatim transcripts revealed three overarching themes experienced by the participants during the implementation of the clinical practices included in the SPI ventilator care bundle: the power of measurement, feedback to peers and experts and improvement tools specific to SPI. Consistent measurement of compliance with the four elements of the bundle and outcomes made the staff realize that their engagement in previous improvement work for ventilated patients was inadequate and motivated them to apply the introduced clinical practices more reliably. Feedback to experts and peers of staff compliance with the four clinical practices and outcome improvement was perceived as a very influential aspect of SPI. Small tests of change (Plan-Do-Study-Act cycles), teaching sessions and daily goal sheets were quoted as particularly useful tools throughout the implementation of the four clinical care practices. Future initiatives that aim to improve the adherence of clinical staff with clinical practice guidelines in intensive care units could benefit from integrating in their methodology consistent measurement and feedback practices of both process compliance and outcome data. [ABSTRACT FROM AUTHOR]