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Since the introduction of the Improving Access to Psychological Therapies (IAPT) programme in NHS England, psychological therapy has gained traction as 'evidence-based' and 'effective' in both clinical and economic terms. In the process, psychotherapeutic care has been reconstituted as highly manualised, standardised, and quantifiable. Drawing on anthropological fieldwork with mental health practitioners, this paper examines some common tensions that practitioners experience in their daily work where psychotherapy is sought within the framework of evidence-based medicine (EBM). For therapists working within IAPT, extensive monitoring and practices of accountability have come to undermine psychotherapeutic efforts to care for patients as 'people'. As a result, many practitioners now feel that they are working in a 'factory of therapy' whereby psychological treatment is recast in the service of outcome measures, and by which critique of the IAPT service, as well as caring relations within it, have been precluded. [ABSTRACT FROM AUTHOR]

In April 2013 the local public health function in England was returned from the National Health Service (NHS) to local government, reversing the transfer to the NHS made in 1974 with the abolition of the medical officer of health. Although many in the field had long felt that local government was the appropriate home for public health given its wide-ranging responsibilities for the social determinants of health, the timing was poor. Local government was in the third year of what continued to be an unprecedented ten-year period of austerity imposed by central government with cumulative cuts of the order of 40% for many local authorities. And despite an initial commitment to a ring-fenced public health grant, this grant has been cut each year since 2015–2016 in addition to the wider local authority funding cuts which have had inevitable knock-on effects on the public health function. Crucial public health services such as early years, smoking cessation and sexual health services have all been cut. Despite these cuts the UK government continues to claim a commitment to improving public health and tackling inequalities in health. This study examines the government's discourse on funding local public health services, and the ways in which it has responded to critics through a detailed documentary analysis of key government white papers, ministerial statements and its responses to criticisms, particularly from parliamentary select committees and professional bodies. The paper concludes by considering the implications for effective local public health action in a national regime of austerity. [ABSTRACT FROM AUTHOR]

A number of studies have previously been published on the benefits of GP appraisal. Ours is the first study that compares the views of doctors registered before and after the introduction of appraisals on various core elements of the appraisal process. This study aimed to explore potential differences, between GPs qualifying before and those after the introduction of NHS appraisals, on the utility of the appraisal process. Additionally, to discover the perceived impact of appraisals on interaction with colleagues and patients. Suffolk appraisers were recruited to distribute a paper questionnaire, in two sections, for each appraisal undertaken over a 12-month period. The first part of the questionnaire related to that specific appraisal. The second part, seven questions using Likert scales and free-text comments, asked about the appraisal process in general. The feedback from the second part forms the data for this study. Overall, doctors tended to agree that appraisals had a beneficial impact in the core areas investigated. However, there was a significant difference between generations: those registered before 1998 were less likely to find NHS appraisals beneficial. Both groups reported that preparation took up too much time. Opinions regarding the impact of appraisals on interaction were evenly divided amongst appraisees, with the older cohort more likely to report negatively. There is a generational difference amongst GP in the perceived utility of NHS appraisal. Current plans to redesign the process to make appraisals less onerous will be welcomed by both groups. [ABSTRACT FROM AUTHOR]

Background: The concept of recovery is contested throughout the existing literature and in mental health services. Little research exists that gives voice to service user perspectives of recovery. Aim: This paper explores how service users in two recovery oriented services run by the National Health Service in North West England talked about recovery and what it meant to them. Method: 14 service users accessing these services took part in semi-structured qualitative interviews focusing on the concept of recovery. Data were analysed using an interpretive phenomenological analysis approach. Results: Service users talked about recovery as a dynamic, day to day process as well as an outcome; specifically related to being discharged from inpatient settings. A number of factors including relationships and medication were cited to have the potential to make or break recovery. Conclusions: The study highlights the continued dominance of the biomedical model in mental health services. Service users appear to have internalised staff and services’ understanding of recovery perhaps unsurprisingly given the power differential in these relationships. Implications for clinical practice are explored. [ABSTRACT FROM AUTHOR]

Whilst an earlier paper (Part 1) in this journal describes the historical, political and economic drivers behind the creation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), this paper (Part 2) focuses on exploring the context within which the service functions. The paper provides an overview of its operational model and is organised into 10 sections. The first section outlines the service's clinical practice, whilst the second addresses the value of GP consultations as a core part of the PCPCS's provision. The third section addresses how the service, as departure from a more ‘pure’ psychoanalytic tradition of providing longer-term therapy, has managed its provision of brief treatments. There is a description of how the service manages its team of multi-disciplinary clinicians and their work in a variety of micro-cultures, conveying some of the challenges faced by the service and the team since its inception. Thereafter, the quantitative and qualitative evidence for the service's clinical and cost effectiveness is assessed, including outcome results and findings from a health economic evaluation. To illustrate some of the service's work in practice, some disguised clinical vignettes are presented. The paper also summarises the service's recent clinical innovations, as well as its contribution to the field of research, audit and training. Finally, the way forward for the service is considered in the context of current and emerging trends in psychological provision in primary care. [ABSTRACT FROM PUBLISHER]

The City and Hackney Primary Care Psychotherapy Consultation Service is an innovative, public sector service designed to support GPs in meeting the needs of patients with complex psychological/physical health issues throughout the London Boroughs of Hackney and the City. This paper provides an account of how this new model for the National Health Service (NHS) developed in the context of psychotherapy provision within the NHS, within the national and local context in the UK and gives an overview of some the service's key features and how it differs from other services operating in primary and secondary care. A linked paper, in this journal, explores the reality within which the service functions and describes clinical outcomes, health economic data, the modifications to the original model and prospects for the future. [ABSTRACT FROM PUBLISHER]

Background/purpose: This paper presents the findings of an action research (AR) project to improve a health information system (HIS) at the Operating Theater Department (OTD) of a National Health Service (NHS) hospital in South East England, the UK.Methods: Informed by socio-technical systems (STS) theory, AR was used to design an intervention to enhance an existing patient administration system (PAS) to enable data entries in real time while contributing to the literature. The study analyzed qualitative data collected through interviews, participant observations, and document reviews.Results: The study found that the design of the PAS was unsuitable to the work of the three units of the OTD. Based on the diagnoses and STS theory, the project developed and implemented a successful intervention to enhance the legacy system for data entries in real time.Conclusions: The study demonstrates the value of AR from a socio-technical perspective for improving existing systems in healthcare settings. The steps adopted in this study could be applied to improve similar systems. A follow-up study will be essential to assess the sustainability of the improved system. [ABSTRACT FROM AUTHOR]

Delivering optimal and equitable palliative care is an international challenge. There are few cross-national comparisons examining challenges in expanding palliative care along public health lines. This paper presents a critical review of palliative care in the USA and England, which share similar challenges but have different contexts of healthcare. Beyond some obvious differences in the organisation of palliative care, a set of underlying common issues can be identified. A key tension in both is balancing attention ‘downstream’ in the dying phase, as well as ‘upstream’ earlier in the course of serious illness. In both, the dominant models of palliative care provision have resulted in excellent care towards the end of life for some patients, but there remain major deficiencies in care for the majority. England has a National Strategy for End-of-life care; the US has no equivalent, although a number of influential agencies have published statements. Achieving a public health approach in palliative care requires international consensus on the meaning and target population of palliative care, replacement of prognosis based understandings of entitlement to palliative care with a needs-based approach and development of an evidence base for cost-effective partnerships between providers across the specialist–generalist divide. [ABSTRACT FROM AUTHOR]

Never before have public sector jobs been so threatened. Fear and anxiety have shifted their focus, from performance to survival. With reference to immediately contemporary works on the NHS in particular, such as Mandelstam (2011) and Leys and Player (2011), the paper establishes the factual validity of the crisis. The authors conducted a series of workshops for public sector staff to enable them to explore their reactions to the current situation. It is possible to identify increasing levels of denial and other forms of resistance to change similar to those first identified by Menzies' (1959). Drawing on the work of Bion (cited Obholzer & Roberts, 1994) the paper considers the dangers of a retreat to the paranoid schizoid position, and identifies a theoretical clue in Halton (2004) for turning the trauma of change into a creative opportunity. Art has access to emotional, spiritual and creative facets of the human mind that science cannot explore. Klein's (1975) consideration of the infantile and regressive aspect of art is acknowledged. The paper then considers what is revealed by a study of specific works of art which were presented in the workshops; including paintings by Bosch, Rousseau, Breughel and Goya. The work of Zagier-Roberts (1998) and Winnicott (1971) is called upon to endorse the usefulness of such a playful collage of responses. Art can be used to help people move through Kubler Ross' stages of bereavement (1997); not to acceptance but out of the paranoid schizoid position into the depressive position (Klein 1975). Revisiting the work of Halton (2004) and the concept of evolutionary creativity, a move on from the depressive position can begin. Collective validation can be affirmed through a rebooting of the essential public sector values while a radical turning away from organisational priorities, to face the service user, provides a more far reaching optimism than any envisaged by an essentially limited demand for modernisation. In conclusion the paper considers the recent contributions of Dienst (2011) and Dumenil and Levy (2011) to advocate tactical resistance to the denigration of the public sphere. [ABSTRACT FROM PUBLISHER]

This paper explores why leadership, especially senior leadership in British organizations, is persistently nearly always white. The paper contends that beneath the veneer of our apparent commitment to equal opportunities, primitive often unconscious factors operate to ensure that leadership remains white, thus reproducing a racial hierarchy in the workplace. It argues that the barriers to black and minority ethnic people getting appointed to leadership positions in organizations today are largely invisible and are hidden within the psyches of decision makers, the cultures of white organizations, and their combined impact on the confidence of black and minority ethnic staff. [ABSTRACT FROM PUBLISHER]

This paper describes a preliminary investigation on the effectiveness of Dynamic Interpersonal Therapy (DIT). The research was undertaken in an inner London primary care psychological therapies service. Outcome data on the symptoms of depression [Patient Health Questionnaire-9 (PHQ-9)] and anxiety [Generalised Anxiety Disorder-7 (GAD-7)] were collected from service-users (n = 24) at the first and last episodes of treatment. There were statistically significant reductions in depression (PHQ-9) and anxiety (GAD-7) associated with DIT, with medium and large effect sizes, respectively. Overall, 75% of patients showed an improvement on the PHQ-9 and GAD-7 following DIT. When this was calculated as statistically reliable change, the improvements reduced to 42% for anxiety and 25% for depression. As this study was uncontrolled, the significance cannot be reliably attributed to DIT. Future research may aim to investigate DIT's effectiveness in different settings with a larger sample size, using appropriate comparison groups under controlled conditions. [ABSTRACT FROM PUBLISHER]

Background Health literacy is important because of the high proportion of the population with skills below those needed to become and stay healthy, and the resultant negative impact on people's lives. A recent study in England has shown that, as is true in other industrialized nations, a significant proportion of people (43–61%) have literacy and numeracy skills below those needed to fully understand and use health materials. This paper describes a project designed to build on these findings with key stakeholders to develop an action plan to address a mismatch between population skills and the health system complexity. Method The multi-stage project involved an initial meeting of stakeholders that allowed participants to share knowledge and experience, and make suggestions for change. Subsequent web-based surveys enabled widening of the stakeholder group, identification of further potential actions, and participant rating of the impact of the suggested actions on this mismatch. Next, a meeting enabled the group to identify priorities for change that would be feasible and cost-effective. Results Forty-one participants were recruited from a range of patient, health, lifelong learning, civil service, and industry perspectives. Suggested topics for action fell into four areas; improving health services, building health literacy skills in the population and workforce, recognizing the importance of public information developed outside the health arena, and funding for health literacy research and development. Following consideration of likely cost, impact, and feasibility, five suggested areas were prioritized for action, three involving improvements in the health service, and two involving the development of public health literacy skills. The importance of inter-sectoral approaches to this complex issue was identified. Discussion This project recruited key stakeholders with a wide range of relevant expertise and perspectives. It resulted in a clear, coherent action plan to address the population skills: health system complexity mismatch. Next steps include implementation, evaluation, and widening to other areas of life important to public health and well-being such as public safety messages and social care. [ABSTRACT FROM AUTHOR]

Objective:This study aimed to explore health visitors’ (HVs) experiences of the assessment of women with psychological distress and mental health problems across the perinatal period in clinical practice.Background:In international contexts, there is now a firm policy remit for the assessment of psychological and mental health disorder across the perinatal period. Women are in regular contact with health professionals across this time and consultations intuitively create an ideal and appropriate context in which to assess women’s psychological health. National reports and academic literature highlight that to prevent the escalation of perinatal mental illness, significant change is needed to support health professionals in detecting, discussing and dealing with mental illnesses.Methods:In a qualitative aspect of a larger mixed-method study, data were collected from two Focus Group Discussions with HVs pre and post a training session related to assessing and managing perinatal mental health problems in practice. For the purposes of this paper, the data were explicitly examined for references to recognition and assessment.Results:Four themes emerged from the data: recognising the problem; questioning and identification; so what do I do now; the importance of support to promote effective identification and assessment.Conclusion:Findings elucidate the complexities that practitioners face in assessing women’s psychological health in real world settings. HVs’ experiences highlight that the implementation of measures into practice needs to be workable and accompanied by contemporary and appropriately contextualised knowledge, adequate service provision and clear referral pathways to ensure effective assessment of women’s psychological health. [ABSTRACT FROM PUBLISHER]

Scientific-bureaucratic medicine (SBM) has been the dominant discourse on evidence-based medicine in the English National Health System (NHS). It has being claimed that SBM has led to new forms of medical professionalism with an emphasis on organisational values and the control of autonomy. This paper explores the medical professions' response to SBM, where SBM is manifested in the form of National Institute of Health and Clinical Excellence (NICE) guidelines. Seventy-four face-to-face informal interviews were carried out with clinicians and managers between 2007 and 2009. Three major themes emerged from the analysis each of which was linked to doctors' receptiveness to NICE guidelines implementation. The first emphasised organisational values, which accounted for conditional acceptance of NICE guidelines. The second was proactive professionalism or entrepreneurial professionalism, which was linked to the rejection of NICE guidelines and the emergence of alternative forms of introducing new ideas for the expansion of their clinical practice. The third was related to the prominence of clinical autonomy linked with doctors' resistance to the use of NICE guidelines. It is argued that this evidence does not reflect a significant emergence of new forms of professionalism but the development of multiple occupational identities. [ABSTRACT FROM AUTHOR]

This paper draws parallels between the market trend in the English NHS and Polanyi's (1957) The Great Transformation: The political and economic origins of our time, Beacon Press: Boston (originally published in 1944 in the United States as The Great Transformation, Rinehart: and Co: New York, and in 1945 in England as Origins of our time, Gollancz: London) account of how the rise of markets provokes a self-protective counter-reaction that tries to re-embed economic relations in social relations. We report findings from a qualitative study of NHS contracting, which examines the recent move to harder-edged contracts with greater use of financial penalties and incentives. In practice, use of these techniques tended to be confined to nationally-mandated sections of the contract rather than emerging from local bilateral agreements, and when things went wrong the parties relied more on cooperative behaviour than on the provisions of the contract to find solutions. Making the current contracting system work depended more on existing relational networks than on the incentive structures created by recent 'marketisation' initiatives, but the inability of the market to evolve as expected has encouraged policy makers to publish plans for further radical reforms. [ABSTRACT FROM AUTHOR]

The authors describe the incremental approach to the marketisation of the English National Health Service (NHS) since the introduction of an 'internal market' in 1990 until the 2010 White Paper, 'Equity and Excellence: Liberating the NHS', and the subsequent Health and Social Care Bill published in January 2011. The introduction of a competitive market for a universal, tax-financed health system requires fundamental changes in regulation in order that market bureaucracy can be substituted for direct management. The components of reform are insufficiently captured by the framework of hierarchies and networks in new public management theories of decentralisation. [ABSTRACT FROM AUTHOR]

In this paper I will attempt to describe the treatment of a seriously ill patient in a National Health Service (NHS) clinic who suffered from recurrent depressive disorder with co-morbidity, repeated breakdowns and was at risk of suicide. The purpose of writing a clinical case study is to illustrate the vital importance of a psychoanalytically-informed approach in the treatment of a very ill patient in the public sector. At a time when there is a decrease in the provision of long-term psychoanalytic psychotherapy my aim is to illustrate its value in the understanding and treatment of complex disorders, a perspective that seems to be under constant threat from internal and external pressures and at risk of being sidelined as a non-evidence-based form of treatment. I will try to describe the different stages in the treatment; from referral through to the beginning of treatment, its interruption, the patient's breakdown and admission, and finally his return to treatment upon discharge. The ending will be discussed with a view to highlighting some of the patient's internal movements enabled by the work undertaken. [ABSTRACT FROM AUTHOR]