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This paper contributes to the literature on ethics in Participatory Research (PR) by looking at the Researcher-in-Residence model and its application within health services research in three East London boroughs. The Researcher-in-Residence is embedded in the organisation to enable knowledge mobilisation and knowledge coproduction. Whereas negotiation of different types of expertise to coproduce evidence might raise issues of power differentials, the embedded nature of the role also requires careful negotiating of relationships. As the researcher is immersed in the context under evaluation, the boundaries between the researcher and the participants’ everyday working life can become blurred. The paper explores these ethical issues and suggests that, whereas the requirements of ethics committees, based on an ethics of principle, at times fail to offer appropriate guidelines for this methodological approach, an ethics of care based on relationships can offer a complementary framework to address some of the thorny challenges that emerge from everyday practice in PR.

Introduction: This paper examines one of the NHS England’s Pioneers programmes of Integrated Care, which was implemented in three localities in East London, covering the area served by one of the largest hospital groups in the UK and bringing together commissioners, providers and local authorities. The partners agreed to build a model of integrated care that focused on the whole person. This qualitative and participatory evaluation looked at how an ambitious vision translated into the delivery of integrated care on the ground. The study explored the micro-mechanisms of integrated care relationships based on the experience of health and social care professionals working in acute and community care settings. Methods: We employed a participatory approach, the Researcher in Residence model, whereby the researcher was embedded in the organisations she evaluated and worked alongside managers and clinicians to build collaboration across the full range of stakeholders; develop shared learning; and find common ground through competing interests, while trying to address power imbalances. A number of complementary qualitative methods of data generation were used, including documentary analysis, participant observations, semi-structured interviews, and coproduction workshops with frontline health and social care professionals to interpret the data and develop recommendations. Results: Our fieldwork exposed persistent organisational fragmentation, despite the dominant rhetoric of integration and efforts to build a shared vision at senior governance levels. The evaluation identified several important themes, including: a growing barrier between acute and community services; a persisting difficulty experienced by health and social care staff in working together because of professional and cultural differences, as well as conflicting organisational priorities and guidelines; and a lack of capacity and support to deliver a genuine multidisciplinary approach in practice, despite the

Organisational Development (OD), with its focus on partnership working and distributed leadership, is increasingly advocated as an effective approach to driving change. Our evaluation of the impact of OD on delivery of integrated care in three London boroughs sheds light on how OD is being understood and implemented within health services, and what impact it is having on delivery of care. The findings presented here are based on a qualitative and participatory evaluation. We looked at how health and social care professionals communicated and coordinated delivery of care and evaluated the impact of current OD activities on the ground to evidence whether and to which degree they are enabling frontline staff to change their working routines towards greater coordination. Our findings highlight the limited reach and scope of a top-down approach to OD based on ad hoc coaching and staff engagement events, often delivered by external consultancies, and mostly focused at the senior management level. This approach fell short of enabling the creation of sustainable, integrated and collaborative organisations. Instead, some of the professionals that participated in our study tried to develop spaces that facilitated ongoing dialogue and mutual support among professionals on the ground. Initiatives of bottom-up OD such as those described in this paper have greater potential to change working routines as they enable staff to move towards more collaborative and coordinated work. These findings contribute to the literature on OD in public services and highlight the benefits of a context-sensitive, pragmatic, and long-term approach to OD to help create sustainable collaborative organisations.

This paper contributes to the literature on ethics in Participatory Research (PR) by looking at the Researcher-in-Residence model and its application within health services research in three East London boroughs. The Researcher-in-Residence is embedded in the organisation to enable knowledge mobilisation and knowledge coproduction. Whereas negotiation of different types of expertise to coproduce evidence might raise issues of power differentials, the embedded nature of the role also requires careful negotiating of relationships. As the researcher is immersed in the context under evaluation, the boundaries between the researcher and the participants’ everyday working life can become blurred. The paper explores these ethical issues and suggests that, whereas the requirements of ethics committees, based on an ethics of principle, at times fail to offer appropriate guidelines for this methodological approach, an ethics of care based on relationships can offer a complementary framework to address some of the thorny challenges that emerge from everyday practice in PR.

Worldwide, policymakers, health system managers, practitioners and researchers struggle to use evidence to improve policy and practice. There is growing recognition that this challenge relates to the complex systems in which we work. The corresponding increase in complexity-related discourse remains primarily at a theoretical level. This paper moves the discussion to a practical level, proposing actions that can be taken to implement evidence successfully in complex systems. Key to success is working with, rather than trying to simplify or control, complexity. The integrated actions relate to co-producing knowledge, establishing shared goals and measures, enabling leadership, ensuring adequate resourcing, contributing to the science of knowledge-to-action, and communicating strategically.

Worldwide, policymakers, health system managers, practitioners and researchers struggle to use evidence to improve policy and practice. There is growing recognition that this challenge relates to the complex systems in which we work. The corresponding increase in complexity-related discourse remains primarily at a theoretical level. This paper moves the discussion to a practical level, proposing actions that can be taken to implement evidence successfully in complex systems. Key to success is working with, rather than trying to simplify or control, complexity. The integrated actions relate to co-producing knowledge, establishing shared goals and measures, enabling leadership, ensuring adequate resourcing, contributing to the science of knowledge-to-action, and communicating strategically.

Although rare, popliteal vein aneurysms can lead to pulmonary emboli, which can be fatal. We present a case of a popliteal vein aneurysm in a 39-year-old female who presented with her third episode of pulmonary embolism despite being on anticoagulants. Computed Tomography Venogram demonstrated a large Popliteal Vein Aneurysm measuring 71 x 36 x 77 mm which was surgically repaired. According to the current literature, anticoagulation is insufficient therefore early surgical intervention is recommended as it is safe and effective.

Although rare, popliteal vein aneurysms can lead to pulmonary emboli, which can be fatal. We present a case of a popliteal vein aneurysm in a 39-year-old female who presented with her third episode of pulmonary embolism despite being on anticoagulants. Computed Tomography Venogram demonstrated a large Popliteal Vein Aneurysm measuring 71 x 36 x 77 mm which was surgically repaired. According to the current literature, anticoagulation is insufficient therefore early surgical intervention is recommended as it is safe and effective.

Item does not contain fulltext, PURPOSE: In phase I/II trials, the cytotoxic T lymphocyte-associated antigen-4-blocking monoclonal antibody tremelimumab induced durable responses in a subset of patients with advanced melanoma. This phase III study evaluated overall survival (OS) and other safety and efficacy end points in patients with advanced melanoma treated with tremelimumab or standard-of-care chemotherapy. PATIENTS AND METHODS: Patients with treatment-naive, unresectable stage IIIc or IV melanoma were randomly assigned at a ratio of one to one to tremelimumab (15 mg/kg once every 90 days) or physician's choice of standard-of-care chemotherapy (temozolomide or dacarbazine). RESULTS: In all, 655 patients were enrolled and randomly assigned. The test statistic crossed the prespecified futility boundary at second interim analysis after 340 deaths, but survival follow-up continued. At final analysis with 534 events, median OS by intent to treat was 12.6 months (95% CI, 10.8 to 14.3) for tremelimumab and 10.7 months (95% CI, 9.36 to 11.96) for chemotherapy (hazard ratio, 0.88; P = .127). Objective response rates were similar in the two arms: 10.7% in the tremelimumab arm and 9.8% in the chemotherapy arm. However, response duration (measured from date of random assignment) was significantly longer after tremelimumab (35.8 v 13.7 months; P = .0011). Diarrhea, pruritus, and rash were the most common treatment-related adverse events in the tremelimumab arm; 7.4% had endocrine toxicities. Seven deaths in the tremelimumab arm and one in the chemotherapy arm were considered treatment related by either investigators or sponsor. CONCLUSION: This study failed to demonstrate a statistically significant survival advantage of treatment with tremelimumab over standard-of-care chemotherapy in first-line treatment of patients with metastatic melanoma.

The purpose of this monograph is to examine the theory behind this assumption of synergy, to identify evidence that supports or refutes the theory, and to suggest the practical and feasible implications of developing a system for public release of information about quality. The recent Institute of Medicine report on medical errors in the United States signals that improving quality of care will be a central political issue for most countries in the developed world in this century. Both the evidence and prior experience suggest that improving quality will be extraordinarily difficult. Thus, it is appropriate and timely that we examine carefully the role that public release of information might play in facilitating more rapid improvement in medical care systems. By examining the contribution of public disclosure of information in the United States, which has experimented most with this technique, we hope to increase our understanding of how quality improvement efforts can be successfully implemented in the UK, and to help quality of care improve more rapidly in the first three decades of the 21st century than it did in the last three decades of the 20th., Prepared in cooperation with the Nuffield Trust, London, UK.

The purpose of this article is to present the findings arising from a three year research project which investigated a major system-wide change in the design of the NHS in England. This radical policy change was enshrined in statute in 2012 and it dismantled existing health authorities in favour of new local commissioning groups built around GP Practices. The idea was that local clinical leaders would ‘step-up’ to the challenge and opportunity to transform health services through exercising local leadership. This was the most radical change in the NHS since its inception in 1948. The research methods included two national postal surveys to all members of the boards of the local groups supplemented with 15 scoping case studies followed by six in-depth case studies. These case studies focused on close examination of instances where significant changes to service design had been attempted. We found that many local groups struggled to bring about any significant changes in the design of care systems. But, we also found interesting examples of situations where pioneering clinical leaders were able to collaborate in order to design and deliver new models of care bridging both primary and secondary settings. The potential to use competition and market forces by fully utilising the new commissioning powers was more rarely pursued. The findings carry practical implications stemming from positive lessons about securing change even under difficult circumstances. The article offers novel insights into the processes required to introduce new systems of care in contexts where existing institutions tend to revert to the status quo. The national survey allows accurate assessment of the generalisability of the findings about the nature and scale of change.

Background: A core component of the Health and Social Care Act 2012 was the idea of devolving to GPs a health service leadership role for service redesign. For this purpose, new clinical commissioning groups (CCGs) were formed in the English NHS. Objectives: This research examined the extent and the methods by which clinicians stepped forward to take-up a leadership role in service redesign using CCGs as a platform. Design: The project proceeded in five phases: a scoping study across 15 CCGs; the design and administration of a national survey of all members of CCG governing bodies in 2014; six main in-depth case studies; a second national survey of governing body members in 2016 which allowed longitudinal comparisons; and a fifth phase of international comparisons. Participants: In addition to GPs serving in clinical lead roles for CCGs, the research also included insights from Accountable Officers and other managers, perspectives from secondary care and other provider organisations; local authority councillors and staff, patients and public, and other relevant bodies. Results: Instances of the exercise of clinical leadership utilizing the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. But, we found other cases where clinicians had stepped forward to bring about meaningful improvements to services. The most notable cases involved the design of integrated care for frail elderly patients and others with long term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: strategy-level work at CCG board level; mid-range operational planning and negotiation at programme board level; and thirdly, the arena of practical implementation leadership at the poi

Background: A core component of the Health and Social Care Act 2012 (Great Britain. Health and Social Care Act 2012. London: HMSO; 2012) was the idea of devolving to general practitioners (GPs) a health service leadership role for service redesign. For this purpose, new Clinical Commissioning Groups (CCGs) were formed in the English NHS. Objectives: This research examined the extent to which, and the methods by which, clinicians stepped forward to take up a leadership role in service redesign using CCGs as a platform. Design: The project proceeded in five phases: (1) a scoping study across 15 CCGs, (2) the design and administration of a national survey of all members of CCG governing bodies in 2014, (3) six main in-depth case studies, (4) a second national survey of governing body members in 2016, which allowed longitudinal comparisons, and (5) international comparisons. Participants: In addition to GPs serving in clinical lead roles for CCGs, the research included insights from accountable officers and other managers and perspectives from secondary care and other provider organisations (local authority councillors and staff, patients and the public, and other relevant bodies). Results: Instances of the exercise of clinical leadership utilising the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. However, we found other examples of clinicians stepping forward to bring about meaningful improvements in services. The most notable cases involved the design of integrated care for frail elderly patients and others with long-term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: (1) strategy-level work at CCG board l

In tune with much international practice, the English National Health Service has been striving to transform health care provision to make it more affordable in the face of rising demand. At the heart of a set of recent radical reforms has been the launch of ‘clinical commissioning’ using the vehicle of local groups of General Practitioners (GPs). This devolves a large portion of the total healthcare budget to these groups. National government policy statements make clear that the expectation is that the groups will ‘transform’ the organization and provision of health services. In this article we draw upon interviews, observations and analysis of internal documents to make an assessment of the extent to which clinical leaders have seized the opportunity presented by the creation of these groups to attempt transformative service redesign.

The purpose of this article is to present the findings arising from a three year research project which investigated a major system-wide change in the design of the NHS in England. This radical policy change was enshrined in statute in 2012 and it dismantled existing health authorities in favour of new local commissioning groups built around GP Practices. The idea was that local clinical leaders would ‘step-up’ to the challenge and opportunity to transform health services through exercising local leadership. This was the most radical change in the NHS since its inception in 1948. The research methods included two national postal surveys to all members of the boards of the local groups supplemented with 15 scoping case studies followed by six in-depth case studies. These case studies focused on close examination of instances where significant changes to service design had been attempted. We found that many local groups struggled to bring about any significant changes in the design of care systems. But, we also found interesting examples of situations where pioneering clinical leaders were able to collaborate in order to design and deliver new models of care bridging both primary and secondary settings. The potential to use competition and market forces by fully utilising the new commissioning powers was more rarely pursued. The findings carry practical implications stemming from positive lessons about securing change even under difficult circumstances. The article offers novel insights into the processes required to introduce new systems of care in contexts where existing institutions tend to revert to the status quo. The national survey allows accurate assessment of the generalisability of the findings about the nature and scale of change.

Background: A core component of the Health and Social Care Act 2012 (Great Britain. Health and Social Care Act 2012. London: HMSO; 2012) was the idea of devolving to general practitioners (GPs) a health service leadership role for service redesign. For this purpose, new Clinical Commissioning Groups (CCGs) were formed in the English NHS. Objectives: This research examined the extent to which, and the methods by which, clinicians stepped forward to take up a leadership role in service redesign using CCGs as a platform. Design: The project proceeded in five phases: (1) a scoping study across 15 CCGs, (2) the design and administration of a national survey of all members of CCG governing bodies in 2014, (3) six main in-depth case studies, (4) a second national survey of governing body members in 2016, which allowed longitudinal comparisons, and (5) international comparisons. Participants: In addition to GPs serving in clinical lead roles for CCGs, the research included insights from accountable officers and other managers and perspectives from secondary care and other provider organisations (local authority councillors and staff, patients and the public, and other relevant bodies). Results: Instances of the exercise of clinical leadership utilising the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. However, we found other examples of clinicians stepping forward to bring about meaningful improvements in services. The most notable cases involved the design of integrated care for frail elderly patients and others with long-term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: (1) strategy-level work at CCG board l

In tune with much international practice, the English National Health Service has been striving to transform health care provision to make it more affordable in the face of rising demand. At the heart of a set of recent radical reforms has been the launch of ‘clinical commissioning’ using the vehicle of local groups of General Practitioners (GPs). This devolves a large portion of the total healthcare budget to these groups. National government policy statements make clear that the expectation is that the groups will ‘transform’ the organization and provision of health services. In this article we draw upon interviews, observations and analysis of internal documents to make an assessment of the extent to which clinical leaders have seized the opportunity presented by the creation of these groups to attempt transformative service redesign.

Background: A core component of the Health and Social Care Act 2012 was the idea of devolving to GPs a health service leadership role for service redesign. For this purpose, new clinical commissioning groups (CCGs) were formed in the English NHS. Objectives: This research examined the extent and the methods by which clinicians stepped forward to take-up a leadership role in service redesign using CCGs as a platform. Design: The project proceeded in five phases: a scoping study across 15 CCGs; the design and administration of a national survey of all members of CCG governing bodies in 2014; six main in-depth case studies; a second national survey of governing body members in 2016 which allowed longitudinal comparisons; and a fifth phase of international comparisons. Participants: In addition to GPs serving in clinical lead roles for CCGs, the research also included insights from Accountable Officers and other managers, perspectives from secondary care and other provider organisations; local authority councillors and staff, patients and public, and other relevant bodies. Results: Instances of the exercise of clinical leadership utilizing the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. But, we found other cases where clinicians had stepped forward to bring about meaningful improvements to services. The most notable cases involved the design of integrated care for frail elderly patients and others with long term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: strategy-level work at CCG board level; mid-range operational planning and negotiation at programme board level; and thirdly, the arena of practical implementation leadership at the poi