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The number of older people dying in long-term care facilities (LTCFs) is increasing globally, but care quality may be variable. A framework was developed drawing on empirical research findings from the Palliative Care for Older People (PACE) study and a scoping review of literature on the implementation of palliative care interventions in LTCFs. The PACE study mapped palliative care in LTCFs in Europe, evaluated quality of end-of-life care and quality of dying in a cross-sectional study of deceased residents of LTCFs in 6 countries, and undertook a cluster-randomized control trial that evaluated the impact of the PACE Steps to Success intervention in 7 countries. Working with the European Association for Palliative Care, a white paper was written that outlined recommendations for the implementation of interventions to improve palliative and end-of-life care for all older adults with serious illness, regardless of diagnosis, living in LTCFs. The goal of the article is to present these key domains and recommendations. Transparent expert consultation. International experts in LTCFs. Eighteen (of 20 invited) international experts from 15 countries participated in a 1-day face-to-face Transparent Expert Consultation (TEC) workshop in Bern, Switzerland, and 21 (of 28 invited) completed a follow-up online survey. The TEC study used (1) a face-to-face workshop to discuss a scoping review and initial recommendations and (2) an online survey. Thirty recommendations about implementing palliative care for older people in LTCFs were refined during the TEC workshop and, of these, 20 were selected following the survey. These 20 recommendations cover domains at micro (within organizations), meso (across organizations), and macro (at national or regional) levels addressed in 3 phases: establishing conditions for action, embedding in everyday practice, and sustaining ongoing change. We developed a framework of 20 recommendations to guide implementation of improvements in palliative care in LTCFs. [ABSTRACT FROM AUTHOR]

There are 1.37 million children and young people (CYP) with special educational needs and disability (SEND) in the UK. These CYP have more complex needs and may require more expertise, support and reasonable adjustments in the dental setting. There are high levels of unmet dental need for this cohort of CYP. Unmanaged dental disease, such as dental caries, can impact on a child's quality of life and wellbeing. All healthcare professionals who have contact with CYP with SEND have an important role to play in trying to improve the oral health of their patients. This can be achieved by educating parents, carers and patients, delivering consistent and supportive dental preventative messages, and where required, liaising with, or signposting to dental professionals. This paper outlines oral conditions that CYP with SEND experience, how they are managed by the dental team, reasonable adjustments, and evidence-based guidelines that should be followed to help prevent and treat oral disease. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has caused huge and disruptive technological changes in the healthcare sector, transforming the way businesses and societies function. To respond to the global health crisis, there have been numerous innovation projects in the healthcare sector, including the fast design and manufacturing of personal protective equipment (PPE) and medical devices, and testing, treatment, and vaccine technologies. Many of these innovative activities happen beyond organizational boundaries with collaboration and open innovation. In this paper, we review the current literature on open innovation strategy during the pandemic and adopt the co-evolution view of business ecosystems to address the context of change. Based on a detailed exploration of the COVID-19-related technologies in the UK and global healthcare sectors, we identify the key emerging themes of open innovation in crisis. Further discussions are conducted in relation to each theme. Our results and analysis can help provide policy recommendations for the healthcare sector, businesses, and society to recover from the crisis. [ABSTRACT FROM AUTHOR]

Cancer mortality rates in low-income and middle-income countries (LMICs) are unacceptably high, requiring both collaborative global effort and in-country solutions. Experience has shown that working together in policy, clinical practice, education, training, and research leads to bidirectional benefit for LMICs and high-income countries. For over 60 years, the UK National Health Service has benefited from recruitment from LMICs, providing the UK with a rich diaspora of trained health-care professionals with links to LMICs. A grassroots drive to engage with partners in LMICs within the UK has grown from the National Health Service, UK academia, and other organisations. This drive has generated a model that rests on two structures: London Global Cancer Week and the UK Global Cancer Network, providing a high-value foundation for international discussion and collaboration. Starting with a historical perspective, this Series paper describes the UK landscape and offers a potential plan for the future UK's contribution to global cancer control. We also discuss the opportunities and challenges facing UK partnerships with LMICs in cancer control. The UK should harness the skills, insights, and political will from all partners to make real progress. [ABSTRACT FROM AUTHOR]

Muslims constitute the largest, fastest growing religious minority in the UK. Globally, nurses are legally, morally and ethically obliged to provide non-discriminatory, person-centred, culturally sensitive care. This obligation includes supporting people with their religious needs where appropriate, but there is evidence this is not always happening, particularly for Muslims in mental health care. This paper reviewed primary research to address the question: Can mental healthcare for Muslims be person-centred without consideration of religious identity? Narrative synthesis and concurrent analysis. Searches were conducted post 2000 in MEDLINE, CINAHL, SAGE, PsychINFO and ASA with terms: 'Muslim', 'Islam* ', 'mental health', 'nurs* ', 'person-cent* ', 'religio* '. Narrative data were analysed for commonalities and themes. Seven studies of sufficient quality were analysed. Unconscious religious bias was the overarching theme linking the findings that healthcare staff felt ill-prepared and lacked necessary knowledge and experience to work with diverse patient groups. Unconscious racial bias contributed to limited cultural/ religious competence in treatment and care. Religious identity is core for Muslim patients, so this group may not be receiving the person-centred care they deserve. Nurses need cultural and religious competence to deliver person-centred, holistic care to diverse patient populations, yet the importance of religious practice can be overlooked by staff, with harmful consequences for patient's mental and spiritual welfare. This paper introduces a welcome pack that could help staff support the religious observance of those Muslim patients/service-users wishing to practice their faith during their stay in health services. [ABSTRACT FROM AUTHOR]

• Reports perspectives of 49 frontline staff from five child protective services. • Systemic supervision used as a "rehearsal space" to plan family conversations. • Family systems understood via lens of hypothesising, circularity and curiosity. • Exploring family perspectives enhanced identification of risks to children. • Systemically-trained clinicians provided supportive practice leadership. The importance of supervision for social work practice is widely accepted. This paper focuses on one type of supervision: systemic group supervision or "systemic supervision". Systemic social work practice is generally a group-based, multi-disciplinary model of service delivery that aims to work therapeutically with the whole family. Central to this model is the use of systemically-informed group supervision. This has been shown to impact positively on the quality of direct practice with families, but what is it about this type of supervision that supports frontline practitioners to practice more skillfully? This paper is based on interviews with 49 frontline staff across five children's services departments in the UK. It identifies the key features of systemic supervision and explores why workers think that developing shared understandings of risk to children supports them to intervene more effectively with families in contact with children's services. These findings contribute to a growing body of knowledge about the practice shaping function of supervision within child and family social work. [ABSTRACT FROM AUTHOR]

Summary Background Presentations to emergency departments (EDs) and patient acuity continue to increase. Whilst strategies to deliver safe patient care in the ED are evolving, emergency nurses need to be well educated through specialist qualifications to enable delivery of advanced patient care. This paper presents a comparative analysis of available international practice and competency standards for nurses graduating from emergency nursing courses in Australia, Canada, New Zealand, the United Kingdom, and the United States. Methods CINAHL, Scopus, Ovid MEDLINE, and Embase were searched for papers, published in English, using the terms: ‘emergency’, ‘accident and emergency’, ‘nursing’, ‘competency’, ‘practice standards’, ‘scope of practice’, ‘regulation’, and ‘specialist standards’. Secondary sources from relevant reference lists and professional websites were also searched. Results The standards from the five countries were common across five domains: clinical expertise, communication, teamwork, resources and environment, and legal. None of the standards were specific to the emergency nursing graduate, and there was variability in the level of expertise required for which the standards apply. Conclusions The available practice standards demonstrated some commonality. Consideration of the utility of a universal framework for informing the development of emergency nursing practice standards and emergency nursing curriculum for nurses wishing to specialise is needed. [ABSTRACT FROM AUTHOR]

COVID-19 brought a lot of children's routine clinical services in the UK to a complete halt in March 2020. The NHS had to radically change the way clinical services are provided with the rapid introduction of telemedicine, virtual consultations, and video conferencing facilities to support team working. This paper describes how Peterborough Child Development Centre rapidly redesigned the services with digital tools to continue offering neurodevelopmental and neurodisability services more virtually. We demonstrate how we adapted our approaches to assess and manage complex long-term conditions with improved quality and outcomes by using digital tools. The changes to the clinical processes and systems are here to stay beyond the COVID-19 pandemic and have the potential to revolutionise the services. [ABSTRACT FROM AUTHOR]

Summary: The publication of the Government''s White Paper on re-validation and GMC proposals will have a profound effect on urologists and the way they practice. This paper looks at the components of re-validation and ‘Good Medical Practice’ and examines how clinicians, particularly urologists, may be assessed to ensure they remain on the specialist register. [Copyright &y& Elsevier]

Abstract: Public and private organisations are investing increasing amounts into the development of healthcare software. These applications are perceived to offer numerous benefits. Software systems can improve the exchange of information between healthcare facilities. They support standardized procedures that can help to increase consistency between different service providers. Electronic patient records ensure minimum standards across the trajectory of care when patients move between different specializations. Healthcare information systems also offer economic benefits through efficiency savings; for example by providing the data that helps to identify potential bottlenecks in the provision and administration of care. However, a number of high-profile failures reveal the safety concerns that arise when staff must cope with the loss of these applications. In particular, teams have to retrieve paper based records that often lack the detail of electronic systems. Individuals who have only used electronic information systems face particular problems in learning how to apply paper-based fallbacks. The following pages compare two different failures of healthcare information systems in the UK and North America. The intention is to ensure that future initiatives to extend the integration of electronic patient records will build on the ‘lessons learned’ from previous systems. [Copyright &y& Elsevier]

Abstract: There is ongoing debate about the best model of service provision for people with an intellectual disability who present severe behavioural challenges. The present paper reviewed research which evaluated a range of UK service provision in terms of impact on challenging behaviour and other quality of life indices. A literature search was carried out for English language papers from 1990 to 2010 using a range of databases. Secondary searches were carried out from references of relevant papers. Very few evaluations were found. The available research indicates that, on the whole, specialist congregate services for individuals with challenging behaviour appear to use more restrictive approaches which have limited effect on reducing challenging behaviour. The evidence for peripatetic teams is somewhat unclear. The two studies reviewed showed positive outcomes, but both had limitations that made it difficult to generalize the results. A similar limitation was found with the sole evaluation of a community based service. It is unlikely that one model of service provision will meet the needs of all individuals, however, more robust evaluations are required of existing service models to allow commissioners, service users, their families and carers to make fully informed choices about effective services for those who challenge. [Copyright &y& Elsevier]

This paper will argue that the UK has seen several phases of public health improvement since the Industrial Revolution, and that each of these can be linked to major shifts in thinking about the nature of society and health itself. The authors are not, however, attempting to delineate firm sequences of events (or imply causality) as this would require a level of analysis of the relationship between economy, society and culture which is beyond the scope of this paper. Rather, it is suggested that each phase of health improvement can be thought of in metaphorical terms as a 'wave'. The first wave is associated with great public works and other developments arising from social responses to the profound disruptions which followed the Industrial Revolution. The second wave saw the emergence of medicine as science. The third wave involved the redesign of our social institutions during the 20th Century and gave birth to the welfare state. The fourth wave has been dominated by efforts to combat disease risk factors and the emergence of systems thinking. Although a trough of public health activity continues from each wave, none exerts the same impact as when it first emerged. This paper will discuss the complex challenges of obesity, inequality and loss of wellbeing, together with the broader problems of exponential growth in population, money creation and energy usage. [ABSTRACT FROM AUTHOR]

Abstract: Improvements in health and longevity in countries such as the UK and USA have radically destabilised notions of ageing and old age. From the 19th century onwards the idea of a natural lifecourse following normatively understood stages ending in infirmity and death has been challenged by social and bio-medical developments. Breakthroughs in bio-gerontology and in bio-medicine have created the possibility of an increasingly differentiated idea of normal ageing. The potential to overcome or significantly reduce the age-associated effects of bodies growing older has led many social gerontologists to argue for a return to a more ‘normatively’ based conception of ageing and old age. This paper examines and outlines the tensions between these different discourses and points out that our understanding of the norm is also fast changing as it intersects with the somatic diversity inherent in contemporary consumer society. Drawing on the theoretical work of Ulrich Beck and Zygmunt Bauman, this paper argues that the normalization of diversity leads to a reworking of the idea of normativity which in turn is reflected in profound transformations at the level of institutional arrangements and legal systems. Such changes not only lead to more discussion of what is legally and socially acceptable but also potentially lead to greater calls for regulation concerning outcomes. In this paper we argue that we need to distinguish between the newly reconfigured domains of the natural, the normal and the normative now being utilised in the understanding of ageing if we are to understand this important field of health. [ABSTRACT FROM AUTHOR]

Abstract: This paper presents an ethnographic account of the implementation of Lean service redesign methodologies in one UK NHS hospital operating department. It is suggested that this popular management ‘technology’, with its emphasis on creating value streams and reducing waste, has the potential to transform the social organisation of healthcare work. The paper locates Lean healthcare within wider debates related to the standardisation of clinical practice, the re-configuration of occupational boundaries and the stratification of clinical communities. Drawing on the ‘technologies-in-practice’ perspective the study is attentive to the interaction of both the intent to transform work and the response of clinicians to this intent as an ongoing and situated social practice. In developing this analysis this article explores three dimensions of social practice to consider the way Lean is interpreted and articulated (rhetoric), enacted in social practice (ritual), and experienced in the context of prevailing lines of power (resistance). Through these interlinked analytical lenses the paper suggests the interaction of Lean and clinical practice remains contingent and open to negotiation. In particular, Lean follows in a line of service improvements that bring to the fore tensions between clinicians and service leaders around the social organisation of healthcare work. The paper concludes that Lean might not be the easy remedy for making both efficiency and effectiveness improvements in healthcare. [ABSTRACT FROM AUTHOR]

Abstract: People that move home within developed countries report, on average, better health than non-movers. Pregnant women, new mothers and infants are particularly mobile, but the limited evidence regarding the relationship between their mobility and health suggests they may not conform to the ‘healthy migrant’ effect. This paper examines the relationship between mobility and health among these groups in the UK, using logistic regression to analyse cross-sectional data for 18,197 families in the Millennium Cohort Study wave one. It compares health status variables among mobile and non-mobile families; describes mobile families’ socio-demographic characteristics; explores associations between health outcomes, reasons for residential moves, and experiences of homelessness; and assesses the association between mobility and health care utilisation, social support and residential satisfaction. The paper concludes that mobile pregnant women, new mothers and infants do have poor health outcomes in comparison to non-movers, but this is primarily explained by their socio-demographic characteristics and the negative circumstances associated with a minority of their moves. Families that moved during pregnancy and infancy had worse self-rated health and depression among mothers, and lower birth weight and higher risk of accidents among infants, than non-movers. Mothers in mobile families were younger and had lower levels of education and owner-occupation than non-movers. After adjustment for socio-demographic characteristics mobility was weakly and non-significantly associated with most health variables with the exception of self-rated health and depression among mothers who moved for negative reasons (such as relationship breakdown or problems with neighbours), or had been homeless since birth. After adjustment mobile families had lower levels of most measures of health care utilisation compared to non-movers, but mothers did not report less frequent social contacts, and those that moved during infancy for positive reasons (such as wanting a better home or neighbourhood) had greater satisfaction with home and area. [Copyright &y& Elsevier]

Abstract: Background: Humour is a complex phenomenon, incorporating cognitive, emotional, behavioural, physiological and social aspects. Research to date has concentrated on reviewing (rehearsed) humour and ‘healthy’ individuals via correlation studies using personality-trait based measurements, principally on psychology students in laboratory conditions. Nurses are key participants in modern healthcare interactions however, little is known about their (spontaneous) humour use. Aims: A middle-range theory that accounted for humour use in CNS-patient interactions was the aim of the study. The study reviewed the antecedents of humour exploring the use of humour in relation to (motivational) humour theories. Participants and setting: Twenty Clinical Nurse Specialist–patient interactions and their respective peer groups in a country of the United Kingdom. Method: An evolved constructivist grounded theory approach investigated a complex and dynamic phenomenon in situated contexts. Naturally occurring interactions provided the basis of the data corpus with follow-up interviews, focus groups, observation and field notes. A constant comparative approach to data collection and analysis was applied until theoretical sufficiency incorporating an innovative interpretative and illustrative framework. This paper reports the grounded theory and is principally based upon 20 CNS–patient interactions and follow-up data. The negative case analysis and peer group interactions will be reported in separate publications. Findings: The theory purports that patients’ use humour to reconcile a good patient persona. The core category of the good patient persona, two of its constituent elements (compliance, sycophancy), conditions under which it emerges and how this relates to the use of humour are outlined and discussed. In seeking to establish and maintain a meaningful and therapeutic interaction with the CNS, patients enact a good patient persona to varying degrees depending upon the situated context. The good patient persona needs to be maintained within the interaction and is therefore reconciled with potentially problematic or non-problematic humour use. Humour is therefore used to deferentially package concerns (potentially problematic humour) or affiliate (potentially non-problematic humour). This paper reviews the good patient persona (compliance, sycophancy), potentially problematic humour (self-disparaging, gallows) and briefly, non-problematic humour (incongruity). Conclusions: The middle-range theory differentiates potentially problematic humour from non-problematic humour and notes that how humour is identified and addressed is central to whether patients concerns are resolved or not. The study provides a robust review of humour in healthcare interactions with important implications for practice. Further, this study develops and extends humour research and contributes to an evolved application of constructivist grounded theory. [Copyright &y& Elsevier]

The UK National Institute for Clinical Excellence (NICE) Clinical Guidelines recommend routine prescription of antidepressants for moderate to severe depression. While many patients accept a prescription, one in three do not complete treatment. We carried out a meta-ethnography of published qualitative papers since 1990 whose focus is patients' experience of antidepressant use for depression, in order to understand barriers and facilitators to concordance and inform a larger qualitative study investigating antidepressant use over time. A systematic search of five databases was carried out, supported by hand searches of key journals, writing to first authors and examining reference lists. After piloting three critical appraisal tools, a modified version of the CASP (Critical Appraisal Skills Programme) checklist was used to appraise potentially relevant and qualitative papers. We carried out a synthesis using techniques of meta-ethnography involving translation and re-interpretation. Sixteen papers were included in the meta-ethnography. The papers fall into two related groups: (1) Papers whose focus is the decision-making relationship and the ways patients manage their use of antidepressants, and (2) Papers whose focus is antidepressants' effect on self-concept, ideas of stigma and its management. We found that patients' experience of antidepressants is characterised by the decision-making process and the meaning-making process, conceptualised here as the ‘medication career’ and ‘moral career’. Our synthesis indicates ways in which general practitioners (GPs) can facilitate concordant relationships with patients regarding antidepressant use. First, GPs can enhance the potential for shared decision-making by reviewing patients' changing preferences for involvement in decision-making regularly throughout the patient's ‘medication career’. Second, if GPs familiarise themselves with the competing demands that patients may experience at each decision-making juncture, they will be better placed to explore their patients' preferences and concerns – i.e. their ‘moral career’ of medication use. This may lead to valuable discussion of what taking antidepressants means for patients' sense of self and how their treatment decisions may be influenced by a felt sense of stigma. [Copyright &y& Elsevier]

Abstract: Containing the ‘outsider’ threat to the information systems of organisations as well as recognising the disruptive potential of ‘insiders’ are fundamentals of security management. However, the recent development of public–private partnerships in the UK requires a reassessment of the continuing utility of such dualities. This paper draws upon a sociological understanding of the complexities of organisational practices as well as a grounded case study of the implementation of the NHS ‘Choose and book’ service across both public and private healthcare organisations in order to challenge these essentialist forms of sociotechnical analysis. The paper proposes a sociomaterial understanding of information systems and organisational dynamics that does not seek to separate out distinct ‘human’ and ‘technical’ information security risks. Rather, it asserts that the organisational outcomes of the introduction of new information systems are necessarily emergent and contingent, and it is with these indeterminate realities that security analysts have to engage. [Copyright &y& Elsevier]

Abstract: Drawing on end of life care as an illustrative case, this paper critically examines the provision of care in the home, identifying a number of inherent tensions. For 60 years the hospital has been the preferred site of care. However, the UK caring division of labour is currently undergoing a process of (re)domestication and the provision of home care is increasingly regarded as a ‘gold standard’ for the organisation of care, in institutional and domestic contexts. In this paper we argue that while ‘home care’ policies serve a range of professional and political agendas, they contain unacknowledged contradictions and strains, creating challenges for both family and professional carers. The realities of home care are examined through reconceptualising qualitative data generated from three research projects concerned with dying in the community. We argue that, whilst previous work has highlighted the burdens the redomestication of care places upon carers, home care philosophies and policies have led to over-romanticised notions of care which privilege the value of caring relationships without acknowledging the dynamic interaction of such social relationships with the actual work of caring. Moreover, such policy trends have created a nexus of social expectations and obligations for which modern society is unprepared. With reference to both end of life care, and home care more widely, we argue that health care planners and professionals need to think more critically about the way care is delivered. Home is not merely about a physical space, but the social and emotional relationships therein. Good ‘home care,’ characterised by attention to patient-centred needs and flexible in design and scope, does not have to be located within the private sphere; relationships may actually be maintained and nurtured by enabling people to have a realistic choice of care in an institution. [Copyright &y& Elsevier]

Abstract: It has long been recognised that respondent characteristics can impact on the values they give to health states. This paper reports on the findings from applying a non-parametric approach to estimate the covariates in a model of SF-6D health state values using Bayesian methods. The data set is the UK SF-6D valuation study, where a sample of 249 states defined by the SF-6D (a derivate of the SF-36) was valued by a sample of the UK general population using standard gamble. Advantages of the nonparametric model are that it can be used to predict scores in populations with different distributions of characteristics and that it allows for an impact to vary by health state (whilst ensuring that full health passes through unity). The results suggest an important age effect, with sex, class, education, employment and physical functioning probably having some effect, but the remaining covariates having no discernable effect. Adjusting for covariates in the UK sample made little difference to mean health state values. The paper discusses the implications of these results for policy. [Copyright &y& Elsevier]

The increasing significance of the role of the general practitioner (GP) in the British National Health Service, evolving from a provider to purchaser and now a key player in the organisation of Primary Care Groups, suggests the need for GPs to possess more and more information about their registered population. GP catchment areas, though an essential basis for providing GPs with important information such as levels of accessibility to surgery, are rarely clearly or accurately defined. Previous approaches towards the definition of GP catchments have been confined to single regionalisation methods, such as mean distance measures, and are prone to problems of either overestimating or underestimating medical service areas. This problem is compounded by a lack of acknowledgement that the application of contrasting catchment methodologies to a common service population has the potential to yield vastly different results which can have serious implications for health care planning and resource allocation. The lack of sophistication in the definition of medical service areas calls for a new methodology to be considered. In this paper, attention is given to the adaptation of multidimensional regional analytical techniques developed outside the health domain and applied in a Regional Health Authority in Northern Ireland. The technique involves the creation of a Synthetic Data Matrix (SDM) which compares patient to GP flow (affiliation) information aggregated at the Census Enumeration District level across a number of catchment areas created using different methodologies. The SDM is then analysed using a modified version of the European Regionalisation Algorithm to create an optimal set of non-overlapping regions according to pre-defined population size and self-containment criteria. The results, a set of compact, robust and highly self-contained catchments, are extremely encouraging. The paper considers the future potential use of such a methodology for health care planning and highlights areas for further research in this field. [ABSTRACT FROM AUTHOR]

The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to medical reporting, such as the 'culture of blame'. There are, however, few detailed qualitative accounts of medical culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are an `inevitable' and potentially unmanageable feature of medical work and incident reporting was therefore `pointless'. It was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of incident reporting must engage with more than the ubiquitous 'culture of blame' and instead address the 'culture of medicine', especially as it relates to the collegial and professional control of quality. [ABSTRACT FROM AUTHOR]

A renewed interest in hospital design in the UK, prompted by the Private Finance Initiative, provides an opportunity to consider hospitals as ‘therapeutic environments’. Noting that the therapeutic value of hospitals is related to their physical, social and symbolic design, this paper argues that ‘expert’ knowledges have encouraged the development of hospitals that all-too-rarely provide benign settings for promoting patient recovery and healing. The recent programme of hospital building in the UK, however, has been accompanied by a vigorous debate over what constitutes good hospital design, with four significant ideas emerging: hospitals should be clinically efficient, be integrated within the community, be accessible to consumers and the public, and encourage patient and staff well-being. Suggesting that all four goals demand careful consideration of the real and imagined spatiality of hospital environments, the paper concludes by suggesting ways that health geographers can contribute to debates surrounding PFI hospital design. [Copyright &y& Elsevier]

This paper uses social conflict theory to reconsider the relationship of American nursing theory and individualised mental health care in the UK. It is argued that nursing theory has developed within a context of ‘American dream’ individualism, and that this ideology may be problematic for some UK mental health nurses and service users whose values and beliefs are those of different socio-political traditions. The paper explores the historical background of Anglo-American nursing theory, and then uses conflict theory to generate challenging propositions about the culture bias and political instrumentality of individualised care in mental health settings. In so doing, it critiques the ‘scientific’ and ‘liberal’ preconceptions of individualised care which have dominated mental health care policy for over a decade. [Copyright &y& Elsevier]

The NHS Breast Screening Programme (NHSBSP) was started in 1988 and is a large, organised cancer screening programme. It is delivered by 80 services across England and screens over 2 million women each year. As a screening programme, it must balance the detection of cancers against possible harm to women who do not have cancer. The NHSBSP was therefore designed with detailed information gathering and performance metrics right from the start. In this review paper, we examine how performance metrics in screening mammography have improved the national screening programme and the further developments and challenges that are expected in the years to come. [ABSTRACT FROM AUTHOR]

Around a quarter of hospital beds in the UK are occupied by patients living with dementia (PWD), and communication impairments are common across all types of dementia, often exacerbated by the hospital environment. Unsurprisingly, healthcare professionals (HCPs) report particular challenges in caring for this patient group, whilst trying to recognise and value their personhood as per the underpinning ethos of person-centred care. However, whilst there is a growing body of research that underlines the importance of communication in dementia care, there is far less that actually examines this communication in real time interaction. Suggestions and pointers for good communication do exist, but these do not tend to be empirically derived, and sometimes conflict with empirical findings. This paper focuses on a specific area of interaction which has previously received very little attention: the way in which healthcare encounters are ended or closed. There is potentially a conflict between a pressure to manage a patient as efficiently as possible, and endeavouring to ensure person-centred care and deal with communication difficulties arising from dementia. Using conversation analysis, we examined forty-one video recordings of HCP/PWD interactions collected from an acute inpatient ward. We identify three phenomena around which there were recurring troubles in our dataset: ‘open-ended pre-closings’, ‘mixed messages’ and ‘non specifics and indeterminate terms’. We conclude that moves towards closing an encounter that appear intuitive to HCPs as competent interactants, and that may represent best practice in other healthcare settings, may in fact serve to confuse a PWD and create difficulties with closings. Our findings underline the importance of examining best practice guidance as it is actually talked into being, using approaches which can unpack the interactional detail involved. They also emphasise the importance of context in the analysis of healthcare delivery, to avoid a ‘one size fits all’ approach. [ABSTRACT FROM AUTHOR]

Clinical trials are typically conducted over a population within a defined time period in order to illuminate certain characteristics of a health issue or disease process. Cross-sectional studies provide a snapshot of these disease processes over a large number of people but do not allow us to model the temporal nature of disease, which is essential for modelling detailed prognostic predictions. Longitudinal studies, on the other hand, are used to explore how these processes develop over time in a number of people but can be expensive and time-consuming, and many studies only cover a relatively small window within the disease process. This paper explores the application of intelligent data analysis techniques for building reliable models of disease progression from both cross-sectional and longitudinal studies. The aim is to learn disease 'trajectories' from cross-sectional data by building realistic trajectories from healthy patients to those with advanced disease. We focus on exploring whether we can 'calibrate' models learnt from these trajectories with real longitudinal data using Baum-Welch re-estimation so that the dynamic parameters reflect the true underlying processes more closely. We use Kullback-Leibler distance and Wilcoxon rank metrics to assess how calibration improves the models to better reflect the underlying dynamics. [ABSTRACT FROM AUTHOR]

This paper seeks to explain variations in acute inpatient length of stay in the National Health Service in England. A model is proposed in which the length of stay is allowed to vary according to patient characteristics, the local supply of NHS care, the local pressure on NHS resources, other non-NHS health care supply factors, and local policy effects. Length of stay data are obtained from the 1991/1992 Hospital Episode Statistics. They are standardized for age, sex and broad specialty group, and are aggregated to the level of small areas with populations of about 10,000. Explanatory variables include socio-economic data from the 1991 Census of Population, health status data, waiting time data, measures of access to inpatient and GP services, and measures of local private health care provision. The paper finds that variability in length of stay is greatest in the over-65 age group. The most important determinants of variations in length of stay are access to NHS hospitals, access to private hospitals, waiting times for elective surgery, indicators of poverty, and indicators of the availability of informal care. [ABSTRACT FROM AUTHOR]

Focusing on the case of time-lapse imaging (TLI), this paper analyses how medical professionals negotiate the use of new 'add-on' fertility treatments in light of the limited evidence available. The data produced by TLI technologies is meant to help professionals identify the best embryo to be implanted. Embryo selection is essential in IVF practice for increasing pregnancy rates and reducing the negative effects of repeated failures. More than 5 years after the introduction of TLI in IVF labs, however, there has been no conclusive randomised control trial (RCT) evidence to show that the tools do indeed have a significant impact on pregnancy rates. Nonetheless, many public clinics in the UK have adopted such technologies. Consequently, our research asks: How is the use of TLI tools legitimised by professionals, in light of contradictory evidence? Focusing on 25 semi-structured staff interviews, we argue that professionals use several strategies to legitimise the use of TLI in the clinic without, however, challenging the tenets of evidence-based medicine (EBM) and the value it places on RCTs. Rather, professionals emphasise various advantages that TLI offers, including its use as a lab tool, its potential for knowledge production in embryology, and the role it plays in the management of patient expectations and course of treatment. This paper contributes to debates on the role of EBM in modern medicine and fertility care specifically – an area where this inter-relationship has been underexplored. We conclude by suggesting avenues towards a more nuanced understanding of EBM as it relates to IVF treatment and a rapidly changing biotechnology context. • Professional legitimation of time-lapse imaging in light of limited evidence. • Data on professional perspectives on the use of new fertility treatments. • Article connects IVF add-on debate to critiques of evidence-based medicine. • In-depth analysis of time-lapse imaging case in UK clinics. • Randomised control trials still considered gold standard in IVF. [ABSTRACT FROM AUTHOR]

Abstract: This paper estimates the pattern of private and public physician visits and hospitalisation by socioeconomic position in two countries in which private healthcare expenditure constitutes a different proportion of the total amount spent on health care: Britain and Spain. Private physician visits and private hospitalisations were quantitatively more important in Spain than in Britain. In both countries, the use of private services showed a direct socioeconomic gradient. In Spain, the use of public GPs and public specialists tends to favour the worst-off, but no significant differences were observed in public hospitalisation. In Britain, with some exceptions, no significant socioeconomic differences were observed in the use of public health care services. The different pattern observed in the use of public specialist services may be due to the high frequency of visits to private specialists in Spain. [Copyright &y& Elsevier]

Policy agendas across the developed world privilege systems transformation, notably shifting the balance of service provision from hospital to community settings. Primary and community health services have pivotal roles in the United Kingdom's longstanding policy ambition of healthcare services transformation, and it is imperative that undergraduate nursing students comprehend community settings as valuable learning environments, places of care and community nurses' roles therein. However, limited community placement learning opportunities means nursing students may be inadequately prepared to work in community settings at the point of initial registration. High fidelity simulated learning is well established within undergraduate nursing curricula. Currently, this learning approach predominantly focuses on acute and secondary care nursing and takes place in simulation centres. Within undergraduate nursing curricula there is limited evidence to support that community-based simulation is utilised with the result that students may struggle to recognise the value of learning opportunities in the community environment. This underpins the rationale for the development of this educational initiative which reflects current health policy agenda of care being provided closer to home. In addition, the new pre-registration 'Future nurse: Standards of proficiencies' (NMC, 2019) acknowledge that registered nurses need to be able to care for people in their own home and in the community setting. This paper describes the co-development and implementation of a pilot, community nursing focused, simulated learning resource within an undergraduate adult field nursing programme in Wales, UK. How one university co-developed and implemented a community focused simulation resource for undergraduate nursing students. • Implementation of a community simulation resource for students to safely experience the 'real world' of community nursing. • Support students to build upon prior learning and facilitate future active learning in a community setting. • Highlighting the importance of integrating theory with practice in the context of care delivery in the community. [ABSTRACT FROM AUTHOR]

Abstract: Today in the England there are around 60,000 children and young people in public care, more than one in 200 of the child population. Over the last 12 months about 100,000 children and young people spent some time in public care, almost one in 100 of the child population and the best estimates are that around 3.4% of adults spent some time in public care during their childhood; this is a relatively common experience. So what are the health and other issues for these children and young people during public care and on into adulthood? This paper uses the Every Child Matters outcomes; being healthy, staying safe, enjoying and achieving, making a positive contribution and achieving economic well-being to organize the evidence from the UK and abroad to answer this question. [Copyright &y& Elsevier]

Regulatory frameworks associated to building design are usually complex, representing extensive sets of requirements. For healthcare projects in the UK, this includes statutory and guidance documents. Existing research indicates that they contain subjective requirements, which challenge the practical adoption of automated compliance checking, leading to limited outcomes. This paper aims to propose recommendations for the adoption of automated compliance checking in the design of healthcare buildings. Design Science Research was used to gain a detailed understanding of how information from existing regulatory requirements affects automation, through an empirical study in the design of a primary healthcare facility. In this study, a previously proposed taxonomy was implemented and refined, resulting in the identification of different types of subjective requirements. Based on empirical data emerging from the research, a set of recommendations was proposed focusing on the revision of regulatory documents, as well as to aid designers implementing automated compliance in practice. • Automated compliance checking has been approached mostly replacing human operations. • Automation can be easily achieved for quantitative and objective requirements. • Subjectivity is still a fundamental constraint in the automated compliance process. • Requirements subjectivity has been identified as natural or artificial. • Need of multiple automated compliance approaches due to diversity of requirements. [ABSTRACT FROM AUTHOR]

Abstract: Postnatal care and support for breastfeeding has been central to the United Kingdom maternity care provision for over 100 years. Over that time the burden of care has shifted from home to hospital and back to home again. In the last 10 years, an evidence base has been distilled around the key components of optimum postnatal care and breastfeeding support but the implementation of these has been hampered by an ongoing tensions between a biomedical and social model and by changes in the organization of community postnatal care. These issues are discussed in this paper which concludes with some new developments in care provision. [Copyright &y& Elsevier]

Abstract: Objective: A previous study which explored homeopathic practitioners’ in depth understanding and experiences of homeopathic consultations identified “connecting” as a key component of the consultation. This paper reports on “connecting” and its role in the consultation. Method: Using a qualitative grounded theory approach data was collected from homeopaths using in-depth interviews, observations of homeopathic consultations and solicited practitioner reflective diaries. Constant comparison assisted code, concept and category formation to form a model of the UK classical homeopathic consultation. Results: “Connecting”, describes a complex notion of relationship in the homeopathic consultation consisting of four dimensions, and performs several roles within the consultation that enable practitioners to elicit symptoms, identify expectations, assist with prescribing, help patients engage with homeopathic principles and stimulate healing. Conclusion: This study shows the homeopath as an important component of the therapeutic context forming complex relationships and using communication that is skills based and inductively shaped to interpret and respond to each individual patient and their narrative in the consultation. Practice implications: This study could have implications for teachers, students and practitioners of homeopathy by influencing training needs, and could prove instructive for other clinicians as homeopaths’ communication style could be used to augment other consultations. [Copyright &y& Elsevier]

Abstract: Over the last two decades, HIV and AIDS have been framed as a “global problem”. In the process, transnational advocacy networks have emerged as important actors, and particular places are recognised as key nodes in global HIV and AIDS governance. Using the example of London, UK, this paper examines how these networks are involved in local articulations of global governance and reveals that ‘global’ processes are inflected by the locations through which networks are routed. The example suggests the need for further analysis of the geographies through which HIV and AIDS is reconfiguring power relations at a variety of spatial scales. [Copyright &y& Elsevier]

Abstract: This paper examines changing patterns in the utilisation and geographic access to health services in Great Britain using National Travel Survey data (1985–2006). The utilisation rate was derived using the proportion of journeys made to access health services. Geographic access was analysed by separating the concept into its accessibility and mobility dimensions. Regression analyses were conducted to investigate the differences between different socio-spatial groups in these indicators over the period 1985–2006. This study found that journey distances to health facilities were significantly shorter and also gradually reduced over the period in question for Londoners, females, those without a car or on low incomes, and older people. However, most of their rates of utilisation of health services were found to be significantly lower because their journey times were significantly longer and also gradually increased over the periods. These findings indicate that the rate of utilisation of health services largely depends on mobility level although previous research studies have traditionally overlooked the mobility dimension. [Copyright &y& Elsevier]

Abstract: This paper considers the rise of ‘leadership’ in discourses relating to the British health service, and the application of the term to increasingly heterogeneous actors. Analysing interviews with NHS chief executives from the late 1990s, and key policy documents published since, we highlight how leadership has become a term of choice among policymakers, with positive cultural valences which previously predominant terms such as ‘management’ now lack. We note in particular how leadership is increasingly conferred not only on those in positions of formal power but on frontline clinicians, patients and even the public, and how not just the implementation but the design of policy is now constructed as being led by these groups. Such constructions of the distribution of power in the health service, however, contradict the picture drawn by academic work. We suggest, therefore, that part of the purpose of leadership discourse is to align the subjectivities of health-service stakeholders with policy intentions, making their implementation not just everyone’s responsibility, but part of everyone’s sense of self. Given the realities of organizational life for many of the subjects of leadership discourse, however, the extent to which leadership retains its current positive associations and ubiquity remains to be seen. [Copyright &y& Elsevier]

Abstract: Over the past two decades, an international trend of exposing public health services to different forms of economic organisation has emerged. In the English National Health Service (NHS), care is currently provided through a quasi-market including ‘diverse’ providers from the private and third sector. The predominant scheme through which private sector companies have been awarded NHS contracts is the Independent Sector Treatment Centre (ISTC) programme. ISTCs were designed to produce innovative models of service delivery for elective care and stimulate innovation among incumbent NHS providers. This paper investigates these claims using qualitative data on the impact of an ISTC upon a local health economy (LHE) composed of NHS organisations in England. Using the case of elective orthopaedic surgery, we conducted semi-structured interviews with senior managers from incumbent NHS providers and an ISTC in 2009. We show that ISTCs exhibit a different relationship with frontline clinicians because they counteract the power of professional communities associated with the NHS. This has positive and negative consequences for innovation. ISTCs have introduced new routines unencumbered by the extant norms of professional communities, but they appear to represent weaker learning environments and do not reproduce cooperation across organisational boundaries to the same extent as incumbent NHS providers. [Copyright &y& Elsevier]

Abstract: In 2009, two seminal documents were published by the United Kingdom (UK) government concerning healthcare services for offenders. The Bradley review into diversion for people with mental health problems and learning disabilities emphasised a need to improve offender health, not least because of the high economic costs to society as a whole resulting from unresolved mental illness, physical ill-health and substance abuse problems commonly experienced by offenders. The Bradley review made wide-reaching recommendations for change, requiring strong partnership between health and justice agencies at both central government and local levels. A framework for the delivery of Bradley''s recommendations has been set out in Improving health, supporting justice, the Department of Health''s offender health strategy which sets out the direction of travel for the next 10years. This paper discusses the reality of working toward improving health services for this marginalised group in the context of the influence of the current straitened financial climate on the allocation of resources to publically funded healthcare in the UK; it examines the historically based, and widely held, belief in the principle of “less eligibility” within our society, whereby there is much public and media resistance to allocating resources to improving care for offenders when other, more “deserving”, groups are perceived to be in continuing need. [Copyright &y& Elsevier]

Abstract: This paper aims to estimate the pattern of physician visits and hospitalisation by socioeconomic position in Great Britain and Spain before and after important changes in their health systems during the 1990s. These changes have been accompanied by a trend toward pro-rich inequality in physician use, especially in outpatient consultation in Great Britain, whereas the pro-poor inequality in GP consultation and the pro-rich inequality in specialist consultation in Spain before the changes have been maintained. Although the pro-rich inequality in hospitalisation observed in both countries before their health system changes continues to be seen, the differences have been reduced, suggesting a trend toward socioeconomic equality in hospitalisation. In any case, with the exception of visits to GP in Spain, in both countries greater use of health services by professionals and managers is observed than for the rest of the population. [Copyright &y& Elsevier]

Abstract: Resource considerations have meant that brevity in health care interventions is a high priority, and have led to a constant striving after ever more impressive time efficiency. The UK''s National Health Service may be described as a kind of ‘fast healthcare’, where everyone is task busy, time is money, bed spaces are frenetically shuffled so as to accommodate the most needy and there appears to be ‘no time to talk’. Indeed, a great many health care encounters are taking place in short ‘blips’ often of 5min or less across a range of sites and involving a vast number of practitioners. In this paper we explore how brief communication can both alienate and be therapeutic for patients. We theorise brief interactions by considering a number of traditions of work in anthropology, linguistics and sociology and conclude that health care providers need to invest much more in the skills and strategies for how best to communicate briefly if it to retain its core tradition of caring for others. [Copyright &y& Elsevier]

Abstract: Autonomy in decision-making has traditionally been described as a feature of professional work, however the work of healthcare professionals has been seen as steadily encroached upon by State and managerialist forces. Nursing has faced particular problems in establishing itself as a credible profession for reasons including history, gender and a traditional subservience to medicine. This paper reports on a focus group study of UK nurses participating in post-qualifying professional development in 2008. Three groups of nurses in different specialist areas comprised a total of 26 participants. The study uses accounts of decision-making to gain insight into contemporary professional nursing. The study also aims to explore the usefulness of a theory of professional work set out by . The analysis draws on notions of interpretive repertoires and elements of narrative analysis. We identified two interpretive repertoires: ‘clinical judgement’ which was used to describe the different grounds for making judgements; and ‘decision-making’ which was used to describe organisational circumstances influencing decision-making. Jamous and Peloille’s theory proved useful for interpreting instances where the nurses collectively withdrew from the potential dangers of too extreme claims for technicality or indeterminacy in their work. However, their theory did not explain the full range of accounts of decision-making that were given. Taken at face value, the accounts from the participants depict nurses as sometimes practising in indirect ways in order to have influence in the clinical and bureaucratic setting. However, a focus on language use and in particular, interpretive repertoires, has enabled us to suggest that despite an overall picture of severely limited autonomy, nurses in the groups reproduced stories of the successful accomplishment of moral and influential action. [ABSTRACT FROM AUTHOR]

Abstract: This paper examines the experiences and perspectives of ex-military servicemen in the UK. It focuses specifically on the complex links between emotional distress and various constructions of ‘masculinity’ in a military context. Aspects of military culture that exacerbate vulnerability and also those that are protective to mental health are identified and discussed with reference to the theoretical constructs relating to hegemonic masculinity. A qualitative research design using semi-structured interviews provided in-depth accounts of the experiences of 20 ex-servicemen aged 23–44, all but one of whom were in the Army. We found that in a military setting hegemonic masculinity is embedded in the construction of a soldier identity and expression of emotion may be seen as inappropriate. As a result soldiers often lack a language with which to express distress (in a context in which they may witness extremely distressing events), which may result in delays in recognising and treating mental health problems. However, constructions of masculinity in this setting to some degree also promote a caring, sharing ethos based on strong inter-dependent bonds. A young soldier who can cope with the stresses of military life ‘becomes a man’, adopts a masculine/soldier identity and is well-placed to benefit from these protective factors, notably the camaraderie that is part of service life. In this manner a caring ethos in which some admissions of weakness may be permissible is situated within hegemonic masculinity. This seeming paradox between hyper masculinity and caring masculinities appears to be embedded within military culture, perhaps reflecting the flexibility and ambiguity inherent in constructions of hegemonic masculinity. [ABSTRACT FROM AUTHOR]

Abstract: This paper describes the application of the principles of evidence based medicine to public health. It recounts the experience of the National Institute for Health and Clinical Excellence in England (NICE) which acquired a remit to develop public health guidance in 2005. Some of the history of the origins of the evidence based approach is described in the writings of Cochrane and others, and the way that this came to be a critical part of the NICE approach to developing clinical cost effectiveness is outlined. The challenge of applying these methods to an evidence base which is social and psychological as well as biomedical is considered. Key problems are identified: the breadth of the evidence base, different analytic levels of explanation, and the length of the causal chain between interventions and outcomes in public health. [ABSTRACT FROM AUTHOR]

Abstract: Health services researchers are increasingly using discrete choice experiments (DCEs) to model a latent variable, be it health, health-related quality of life or utility. Unfortunately it is not widely recognised that failure to model variance heterogeneity correctly leads to bias in the point estimates. This paper compares variance heterogeneity latent class models with traditional multinomial logistic (MNL) regression models. Using the ICECAP-O quality of life instrument which was designed to provide a set of preference-based general quality of life tariffs for the UK population aged 65+, it demonstrates that there is both mean and variance heterogeneity in preferences for quality of life, which covariate-adjusted MNL is incapable of separating. Two policy-relevant mean groups were found: one group that particularly disliked impairments to independence was dominated by females living alone (typically widows). Males who live alone (often widowers) did not display a preference for independence, but instead showed a strong aversion to social isolation, as did older people (of either sex) who lived with a spouse. Approximately 6–10% of respondents can be classified into a third group that often misunderstood the task. Having a qualification of any type and higher quality of life was associated with smaller random component variances. This illustrates how better understanding of random utility theory enables richer inferences to be drawn from discrete choice experiments. The methods have relevance for all health studies using discrete choice tasks to make inferences about a latent scale, particular QALY valuation exercises that use DCEs, best-worst scaling and ranking tasks. [Copyright &y& Elsevier]

Abstract: This paper explores the benefits and drawbacks of new team-based approaches to error management in medicine through a case study of teamwork, double witnessing and incident reporting in assisted conception clinics in the UK. This is based upon the analysis of a series of semi-structured interviews with people working in assisted conception clinics and two periods of ethnography in clinics, conducted between 2004 and 2007, as part of an ESRC-funded study on the ethics of assisted conception and embryo research. In common with other studies of practitioners'' management of error, I identify a series of tensions around individual and collective autonomy in identifying and preventing error, for the assisted conception team as a whole, and for particular groups within it, notably consultants and embryologists. I found that team-based approaches could create the conditions for error to occur when it undermined independent thinking, responsibility or concentration. There was also a danger that teamwork could come to be associated with particular ‘technical’ practices or occupational groups, diminishing its relevance and value in clinical settings. I, therefore, conclude that team-based approaches and professional autonomy have their ‘dark’ as well as their ‘light’ sides (Vaughan, D. (1999). The dark side of organisations: mistake, misconduct, and disaster. Annual Review of Sociology, 25, 271–305). Errors cannot be prevented in their entirety, but they can be well managed when teamwork and autonomy are complementary. Drawing on Reason (Reason, J. (2004). Beyond the organisational accident: the need for “error wisdom” on the frontline. Quality Safety in Health Care, 12, ii28–ii33), I argue that informed vigilance and intelligent wariness in a necessary compliment to systems-based approaches to error management in assisted conception in particular, and medicine in general. [Copyright &y& Elsevier]

Abstract: This paper proposes a new approach to the measurement of inequality and inequity in the delivery of health care based on contributions from the literature on poverty and deprivation. This approach has some appealing characteristics: (1) inequity is additively decomposable by population subgroups; (2) the approach does not rely on socio-economic ranks; (3) it provides a graphical representation of the distribution of inequity; (4) it offers a range of indices consistent with dominance. An empirical application is provided investigating the effect of the GP fundholding reform on equity in English NHS. The results show that the most equitable GP practices self-selected into the scheme in 1991; evidence of an inequity-reducing treatment effect as well as a self-selection effect are found in 1992 and 1993; the self-selection process reduces and no evidence of a treatment effect is present thereafter. [Copyright &y& Elsevier]

Abstract: Care pathways are multidisciplinary care management technologies which map out chronologically activities in a healthcare process. In the UK, they are advanced as a mechanism for enacting the changes called for under clinical governance. The terminological imprecision of care pathway methodology has enabled it to align clinical, management and service user interests and helps to explain the growing popularity of care pathways as quality improvement tools. Whilst it is possible to identify a ‘zone of agreement’ between these social worlds, there exists a fuzzy periphery characterised by conflicting agendas, which presents challenges for those charged with inscribing these interests into the pathway artefact. Drawing on a qualitative case study of a mental health safety care pathway in the UK, this paper examines the processes by which originators negotiated and settled upon a given design. The data reveal inherent tensions within pathway technology and the knowledge developers draw upon in devising strategies to overcome these challenges. [Copyright &y& Elsevier]

Abstract: This paper explores the continuities and discontinuities in recent policy on the extension of palliative care to people with heart failure in the UK. It focuses on how professionals in cardiology and specialist palliative care negotiate their disciplinary boundaries within the context of these policy moves. It draws out the semantic, historical and practical tensions between the core values of cardiology, with its focus on ‘living with heart failure’, and specialist palliative medicine, with its focus on ‘dying with heart failure’. A focus on negotiation of interdisciplinary boundaries reveals different engagements with notions of dying and palliation rather than simply different disease trajectories. Further, uncertainty about prognosis and the probability of sudden death pose a challenge to two core principles of specialist palliative care: ‘open awareness’ and ‘good death’. We are not suggesting that these differences are insurmountable. Rather, in highlighting these tensions, our aim is to problematise the relationship between policy and practice, as being mediated by negotiations of disciplinary values (culture) within a local context. We conclude by recommending a wider discussion on notions of ‘open awareness’ and how professionals within different medical disciplines engage with alternate ways of dealing with uncertainty and sudden death as part of human condition. The arguments presented here are based on data and analysis from a larger qualitative study conducted during 2004–2005 in north and central England. [Copyright &y& Elsevier]