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Context The White Paper, The New NHS: Modern, Dependable, once again heralds change and new expectations of primary care in the UK. Objectives This discussion paper aims to encourage reflection on the implications for primary care teams of current governmental strategy, and to address the pivotal role which education can play in equipping practitioners for their roles. Key areas The paper examines the opportunities and threats for primary care in the new NHS developments, the strengths and weaknesses of the role that education currently plays in primary care, and how recent innovations might be used to give a more holistic approach to the needs of practitioners. The challenges for clinical governance of lay engagement and ethical decision making are seen as two crucial outcomes for an educational strategy which must be practice-led, and must interface individual practitioner education with the needs of the team and the community as a whole. I draw on a range of policy documents and educational literature to alert the reader to the different choices which can be made when thinking about appropriate educational models and methods; and offer a detailed structure for a practical educational strategy that may effectively unite theory and practice. The key elements are a three-tier link between practices, primary care groups, and district-level resources for all educational and training activity, and the aim of continuing multiprofessional development which will underpin the new NHS. [ABSTRACT FROM AUTHOR]

The 1944 Wartime Coalition White Paper, "A National Health Service" is unlikely to be celebrated among the spate of golden anniversaries of welfare reforms in the 1990s. However, a study of this document may be of interest for two main reasons. First, it has some parallels with the reformed National Health Service of the 1990s and, second, there have been recent calls for a local government-based health service, as was envisaged in 1944. The White Paper is examined in the context of evolving plans for the NHS, and is compared with the actual shape of the NHS as introduced by the Labour Minister of Health, Aneurin Bevan, in 1948. Four themes are drawn out. First, the White Paper should not be seen as the embodiment of a political consensus. Second, a Conservative Health Service would have differed from the NHS in fundamental aspects. Third, the conceptual advantages of a local government-based health service were outweighed by practical politics. Fourth, although the Labour Party made a difference to the shape of the NHS, that shape did not simply follow from party policy. This implies that medical pressure was successful, to some extent, in defining the limits of the new service. [ABSTRACT FROM AUTHOR]

This paper summarises and discusses some of the aspects of the Public Health White Paper, Healthy Lives, Healthy People, published for consultation at the end of 2010, and the framework of the Public Health Responsibility Deal, published in March 2011 by the UK government. Healthy Lives, Healthy People emphasises that a one-size-fits-all approach to public health improvement has been shown not to work as challenges vary from one neighbourhood to the next, and a new approach that empowers individuals to make healthy choices and gives communities the tools to address their own needs is required. It highlights the government's intention to shift power and decision making on public health matters to local authorities, with ring fenced budgets. A feature of the document that has proved controversial is the proposal to work collaboratively with business and the voluntary sector to deliver the government's ambition, through the Public Health Responsibility Deal, launched on 15 March, which comprises a series of 5 networks on food, alcohol, physical activity, health at work, and behaviour change, and the associated pledges. The initial pledges for the food network focus on salt and trans fatty acid reduction, and out-of-home calorie labelling of foods. [ABSTRACT FROM AUTHOR]

Investigates the National Health Service white paper on the political economy of health care markets in Great Britain. Analysis of the potential consequences of the reforms to introduce supplier competition in health care; Implication of a conventional welfare framework of efficiency and the distribution of resources on consumer choice; Assessment of the scale economics in the production of health care.

This paper evaluates ways in which labour issues in global value chains for medical gloves have been affected by, and addressed through, the COVID‐19 pandemic. It focuses on production in Malaysia and supply to the United Kingdom's National Health Service and draws on a large‐scale survey with workers and interviews with UK government officials, suppliers and buyers. Adopting a Global Value Chain (GVC) framework, the paper shows how forced labour endemic in the sector was exacerbated during the pandemic in the context of increased demand for gloves. Attempts at remediation are shown to operate through both a reconfigured value chain in which power shifted dramatically to the manufacturers and a context where public procurement became higher in profile than ever before. It is argued that the purchasing power of governments must be leveraged in ways that more meaningfully address labour issues, and that this must be part of value chain resilience. [ABSTRACT FROM AUTHOR]

Background: In Britain's National Health Service (NHS), medical consumerism is disliked by many doctors but managed by NHS leaders. Managed consumers have choices about treatment options, but are expected to help contain costs, improve quality of care, take part in clinical research and advocacy, and increase productivity. There are so many meanings for medical consumerism that it can be categorized, in post‐structuralist terms, as a 'symbol without meaning', but meanings are plentiful in the NHS. Policy expectations: Choices made by discriminating consumers were expected to improve the quality of medical care for all. Extending choice to the many, and not restricting options to the few, would allow gains from choices to accumulate, so that choice would sustain social solidarity. Managed consumerism would in theory, therefore, instil reasonable choices and responsible behaviours in a moralized citizenry, across the nation. The advocates of New Labour's espousal of medical consumerism expected the accumulative effects of customer choices to challenge professional and occupational power, erode the medical model of health and illness, constrain professional judgements, and open the NHS to new ways of working. Almost all their expectations have been thwarted, so far. Conclusions: Managed consumerism is far from being a meaningless symbol. This discussion paper explores the territory of managed consumerism and suggests realistic ways to make it more effective in shaping the NHS. Patient & Public Contribution: We developed the arguments in this discussion paper with insights provided by a lay expert (see Acknowledgements) with experience of consumerism in both public sector management and a disease‐related charity. [ABSTRACT FROM AUTHOR]

This paper is a slightly revised version of a Memorandum requested by the House of Commons Social Services Select Committee to assist the Committee in its analysis of the White Paper Working for Patients (Cm 555). It was submitted to the Committee on 28 February 1989. The paper follows up the author's earlier study of the reform of the NHS (Barr, Glennerster and Le Grand, 1988), prepared at the request, of the Select Committee prior to the publication of the White Paper. The success or failure of the White Paper depends crucially on the precise details of the way in which its proposals are implemented. The Working Papers, although providing some more information as to how the White Paper's proposals will be implemented, do not in the main address the issues that concern us here. Given the inescapable tension between cost and quality, quality control will be absolutely critical if the incentives to economize on the use of resources are not on occasion to lead to unacceptable reduction in quality-reduction which might well apply differentially by socioeconomic group. [ABSTRACT FROM AUTHOR]

The article focuses on the White Paper on community care titled "Caring for People" in relation to the 1990 National Health Service and Community Care Bill pending in the House of Lords. Criticisms levelled against the White Paper, particularly the issue of grant aid, are misplaced. The White Paper's outstanding value is that it outlines a clear structure and a set of general principles which should grant local authorities greater autonomy, authority and responsibility in healthcare administration.

The role of medical journal publishing has both an academic function, to inform and communicate research, while for the profession it provides a structured area for debating changes in practice in order to establish suitable protocols for treatment. In addition, such publication is part and parcel of the academic reward system, effecting rank, prestige and salaries and is reflected in the structure of research assessment exercises. Within the postgraduate education of doctors the publication of papers provides a means to distinguish levels of participation in research and experience within specialities. In April 2003 the number of serial titles indexed by NLM stood at 3799 within Index Medicus, 4498 titles in Medline and almost 10000 titles in the list of serials indexed for online users. By March 2003 these figures had increased to 3923, 4579 and 10192 respectively. Apart from the output of learned societies, professional bodies and universities a large proportion of titles are commercially produced.

Following the decision to establish an Advanced Biomedical Scientist Practitioner grade for senior biomedical scientists in the NHS Cervical Screening Programme, a conjoint examination board has been appointed by the Royal College of Pathologists and Institute of Biomedical Science to oversee the Certificate in Advanced Practice in Cervical Cytology examination. The examination consists of a multiple-choice paper, short-answer written questions and practical microscopy sections covering screening of unmarked slides, and more complex discussion cases. In the first year there were 58 entries with 29 successful candidates, a pass rate of 50%. The standard of performance in the examination showed a wide range, and some candidates appear to have underestimated the degree of preparation, knowledge or level of microscopy skill required. [ABSTRACT FROM AUTHOR]

The UK National Health Service (NHS) is changing. Consecutive UK industrial strategies have supported the shift from an NHS that provides free‐at‐point‐of‐delivery healthcare to one that also facilitates research. Said to promote healthcare's triple aim of 'better health, better healthcare, and lower cost' (Wachter, 2016, 3), the digitisation of patient records is a core part in opening routine aspects of the health system to potential research. In this paper, we thematically analyse 11 policy documents and ask, how does the NHS discuss its decision to digitise patient records and what are the implications of such practices on the citizen? We document how (1) digitisation is presented as a collective endeavour for patients and NHS professionals, offering new possibilities for patients to participate in their own health and that of the population through research and, (2) digitisation contributes to the building of an efficient health system. Through this analysis we reflect on how discussions of digitisation present uncritically the potential of Electronic Health Records and big data analytics to improve care and generate wealth through research, and reconfigure patienthood, by placing research participation as a routine part of accessing NHS healthcare. [ABSTRACT FROM AUTHOR]

This paper argues that the terms on which GPs entered the NHS, as self-employed contractors, have proved remarkably resistant to the managerial pressures which have come to dominate other sections of the National Health Service. However, this traditional mode of financing and organizing the delivery of a key element of the National Health Service has become increasingly incompatible with wider health policy objectives — the development of an integrated network of good-quality, equitable and well-coordinated primary and community health services which are responsive to local needs. Furthermore, primary health services have themselves come to play a crucially important role in securing other strategic changes in the wider health policy arena, such as securing and sustaining a shift in the traditional balance between hospital and community-based health services and controlling expenditure in a needs-led service. The paper argues that, notwithstanding the change of government, the 1997. NHS (Primary Care) Act and the White Paper "The New NHS" are both integral to the achievement of wider strategic health policy objectives, such as improving the quality and coherence of services, and increasing professional accountability for the financial consequences of clinical decisions. However, the greatest significance of these and other related measures is that they shift the emphasis of health policy from commissioning and purchasing by primary care to commissioning and contracting for primary care. They thereby extend the exposure of GP-based services to managerialist scrutiny and control. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic and Brexit were separate yet inter‐related developments which affected the British National Health Service (NHS). The UK's state‐funded health sector had historically relied on migrant labour and depended on a migration infrastructure designed to solve its nursing labour shortages. The analysis of primary qualitative and secondary quantitative data shows that the NHS migration infrastructure increased its orientation towards Asia to compensate for the effects of Brexit. The paper reveals how the persistent use of temporary visas along with conditional contractual arrangements has led to various exclusions for migrant nurses and midwives. These data also demonstrate how international travel restrictions associated with COVID‐19 created temporary obstacles for nurses' inflows. Alongside Brexit, this has also resulted in an increase in outflows amongst EU health workers. The article identifies the development of migrant support infrastructure amongst Filipino and Indian nurses as a major COVID‐19 linked innovation. [ABSTRACT FROM AUTHOR]

Aims and objectives. The aim of this paper is to reflect on how an acute hospital trust involved a youth council comprising 17 young people aged 11–18 years to improve children’s service delivery in one NHS trust in the UK. Background. Over the last decade, there has been an increased emphasis on the active involvement and participation of children and young people in the decision-making processes that affect them. However, one challenge in involving users in acute hospital trusts is how their views are used to develop services. For this reason, University Hospitals Coventry and Warwickshire NHS Trust, UK (University Hospitals Coventry and Warwickshire NHS Trust have given permission to have their name cited in the publication of this article) recognising the emerging national patient and public involvement agenda, planned and developed a youth council for the Trust in 2006. Process. The process of setting up the youth council is outlined. An evaluation workshop took place with 15 members of the youth council and their views are incorporated around three specific areas: • Evidence that their involvement has improved trust services; • Barriers to young people’s voices being heard in service delivery; • What could promote young people’s involvement in healthcare services. Conclusion/Relevance to clinical practice. This paper describes the setting up of a youth council but also discusses the potential barriers and how to overcome them to promote young people’s involvement in hospital trust service planning and development. Whilst the focus of the council was young people, the principles are of use to a wide range of clinical professionals faced with similar challenges. [ABSTRACT FROM AUTHOR]

Clinical governance has been acknowledged as the driving force behind National Health Service (NHS) reform since the government white paper outlined a new style of NHS in the UK in 1997. The framework of clinical governance ensures that NHS organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will develop. A major component of a clinical governance framework requires utilizing audit procedures, which assess the effectiveness of current systems and ultimately direct continual quality improvement. This paper describes the audit component of a local clinical governance framework designed for a unit based within an NHS trust, which has utilized a multidisciplinary approach to assess the effectiveness of a newly commissioned service and its impact on the residents and staff. The unit is a 12-bedded, low-secure-intensive rehabilitation unit for clients with severe and enduring mental illness. Using recognized and standardized psychometric outcome measures, information was collected on clinical symptoms, social functioning, social behaviour, quality of life, relationship quality with named nurses and medication side-effects. Additionally, confidential staff measures were included to assess levels of burnout, identify expressed emotion and assess staff perception of models of illness. The paper includes a comprehensive account of how managerial commitment, teaching processes and application of technology ensured prompt data collection and maintained the momentum through the audit timescale. Data analysis and presentation of data in both clinical reviews and in senior management meetings within the unit are discussed. Findings highlight the full integration of the audit system into the processes of the unit. Clinically, the paper highlights the enhancement of the knowledge base of the client group and the influence on clinical decision-making processes and care delivery as a result of the audit. Brief clinical examples are given. In conclusion, the impact of the audit on unit strategy and organizational efficiency are discussed to highlight the importance of closing the audit loop and completing the cycle of clinical governance. The audit system has positive implications for replication in other services. [ABSTRACT FROM AUTHOR]

Accessible summary The governments in the UK want people with learning disabilities to have a voice about what happens in their own life and also in policy., One way of doing this is through research. This paper looks at two inclusive research projects, which were about people using direct payments and personal assistants. The projects both employed people with learning disabilities., Each of these projects made a training pack from the research, so that they would help people with learning disabilities and their supporters. They also had some effects in ways that were not planned, because the government wanted to learn from them about inclusive research., All research seems to have most effect when there are many voices seeking change, including those of policy makers themselves., Inclusive research is a way of achieving 'choice and control'. But just like with direct payments and personal budgets, the best way in these projects was to have good support from other people who will listen to you, and help you decide things for yourself., Summary Participation, voice and control have long been central concerns in the research at Norah Fry. This paper focuses on inclusive research relating to choice and control, as experienced by people with learning disabilities who use personal budgets and direct payments, and aims to question how the process of inclusive research can be linked to wider outcomes. The paper gives a brief overview of two studies carried out by Norah Fry Research Centre, which were in partnership with self-advocacy groups and employed people with learning disabilities, between 1999 and 2007. Both in research and in everyday life, we question individual notions of 'choice and control', showing how relational autonomy was at the heart, both of the process of the inclusive research and also of the outcomes and findings. However, all social research seems to have greatest impact when there is a 'bandwagon effect' of policy and practice initiatives. The discussion considers how the impact of inclusive research designs can be at policy, practice and 'direct' user level and is often achieved by people with learning disabilities having a voice at the dissemination stage. [ABSTRACT FROM AUTHOR]

This dissertation study investigates the ways that NHS libraries are currently marketing their services within their organisation and was submitted as part of the MA Library and Information Management at the University of Sheffield in 2019. This paper presents the findings from twelve semi‐structured interviews carried out with NHS library managers in the East of England to identify the most and least successful methods, and in comparison with that which is currently in the general marketing literature. The study found that outreach marketing was the most effective and that librarians are currently conducting marketing to the best of their ability, but they lack time and funding to be able to make the most of their promotional campaigns. F.J. [ABSTRACT FROM AUTHOR]

The reforms to the NHS following the White Paper, Working for Patients, were presented by the Conservative government as promoting devolution, defined as "decisions … taken at the lowest possible level" by Douglas Hurd (1991) -- reflecting a senior Minister's interpretation of the overall policy agenda, including health. It was further claimed that such policies ("reforms in hospitals, in schools and in housing") were a way to "empower citizens". This approach was naturally an attempt to present the Conservatives' policy as pro-community and 'practical' rather than 'ideological' or free-market obsessed. It is worth renewing the debate about whether power and/or responsibility were devolved in the NHS -- or, indeed, to the NHS from the Department of Health. Rudolf Klein, in the first edition of his The Politics of the National Health Service (1983), had no sooner pointed to the 'devolution' inherent in the 1982 reorganization of the NHS (based on the document Patients First (HMSO, 1981) when the Griffiths Inquiry recommendations were accepted. As a result, he was soon to observe that the pendulum -- at that time -- had quickly swung back to centralism, an observation reiterated after a few years when The Politics of the National Health Service came out in its second edition (Klein, 1989). In other words, there may be a cycle from centralism to devolution and back, or at least an interpretation of events as such in health policy, which makes a current reassessment timely. Which direction did the NHS Act of 1990 and related initiatives embody? [ABSTRACT FROM AUTHOR]

A wide ranging set of reforms is being introduced into the English National Health Service (NHS). They are designed to increase the market-like behaviour of providers of care with a view to improving efficiency, quality and responsiveness of services. This paper is concerned with one aspect of those reforms: namely the policy to increase the diversity of types of providers of care to NHS patients. In this context, increasing diversity means that providers will not all be standard publicly owned NHS organizations. They can be publicly owned but autonomous, or independent (both in for-profit and not for profit). The paper discusses the wide range of organizational forms available, analyzing their governance structures It then discusses the small amount of evidence currently available about the performance of diverse providers of health care. [ABSTRACT FROM AUTHOR]

Consumer involvement is an established priority in UK health- and social-care service development and research. To date, little has been published describing the process of consumer involvement and assessing ‘consumers’ contributions to research. This paper provides a practical account of the effective incorporation of consumers into a research team, and outlines the extent to which they can enhance the research cycle; from project development and conduct, through data analysis and interpretation, to dissemination. Salient points are illustrated using the example of their collaboration in a research project. Of particular note were consumers' contributions to the development of an ethically enhanced, more robust project design, and enriched data interpretation, which may not have resulted had consumers not been an integral part of the research team. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to provide information about cost-effectiveness analysis and the roles of clinical pharmacologists generally in providing efficient health care. The paper highlights the potential consequences of ‘off-label prescribing’ and ‘indication creep’ behaviour given slower growth (or potential cuts) in the NHS budget. This paper highlights the key roles of clinical pharmacologists in delivering an efficient health care system when resources are allocated using cost-effectiveness analyses. It describes what cost-effectiveness analysis (CEA) is and how incremental cost-effectiveness ratios (ICERs) are used to identify efficient options. After outlining the theoretical framework within which using CEA can promote the efficient allocation of the health care budget, it considers the place of disinvestment within achieving efficient resource allocation. Clinical pharmacologists are argued to be critical to providing improved population health under CEA-based resource allocation processes because of their roles in implementation and disinvestment. Given that the challenges facing the United Kingdom National Health Service (NHS) are likely to increase, this paper sets out the stark choices facing clinical pharmacologists. [ABSTRACT FROM AUTHOR]

Although the National Health Service was created to achieve equity of access to health care in 1948, over twenty years later an ‘inverse care law’ was seen to operate. The 1976 Report of the Resource Allocation Working Party laid the principles of formula funding to achieve an equitable distribution of resources, to move, over time, towards the operation of a proportionate care law. These principles have been applied ever since in England. This paper describes the context, governance and subsequent development of formulas and three persistent problems: accounting for populations, their needs and variations in the unavoidable costs of providers. The paper concludes by outlining continuing problems from the past and new challenges of formula funding in England to reduce ‘avoidable’ inequalities in health. [ABSTRACT FROM AUTHOR]

With one in three people likely to experience mental health problems during their lifetime, it is paradoxical that stigma and negative attitudes towards mental illness are so prevalent in the UK today. This systematic literature review was completed to investigate what the most common negative attitudes towards mental illness are, and the most common recommendations made to address them. The findings were used to inform teaching resources used in an National Health Service Direct call centre. Guidelines for undertaking a systematic review, produced by the Centre for Reviews and Dissemination, were used. Terms were set and a search of electronic databases and peer-reviewed academic journals was completed, from which 16 primary research papers (from the UK) were obtained and used. These were assessed, using evidence-based critical appraisal tools, to obtain data pertinent to the original question. This paper describes the process, including a detailed account of the methodologies employed to gather and analyse relevant data. Put into context, alongside key drivers (e.g. government papers), the findings are presented and discussed, along with underlying theories, where appropriate. Recommendations for professional practice are then presented. [ABSTRACT FROM AUTHOR]

Attempts to 'modernize' the English National Health Service (NHS) have included significant workforce re-design, including the development of new, advanced roles in nursing. There is a wealth of evidence documenting and evaluating such roles in hospital and, to a lesser extent, in community settings. This paper builds on this work, drawing on recent post structural and sociological analyzes to theorize these roles, locating them within broader social and cultural changes taking place in healthcare and exploring how understandings of new roles in community nursing are in the process of being constructed. Building on a literature review, the paper draws out what an analysis of new advanced nursing roles in the community reveals about competing conceptualizations of the nursing mandate, the ambivalence and ambiguity that practitioners experience in shaping 'new' identities (the shaping of subjectivities), and the often implicit ideological positions that underpin such developments. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: This paper shows that overseas nurses (OSN) recruited to UK hospital trusts become deskilled in technical aspects of clinical practice. BACKGROUND: Existing research reports that many newly recruited OSN are prevented from using technical skills acquired in training abroad, to the detriment of the National Health Service (NHS) and the concern of the nurses themselves. DESIGN: The author conducted case study work in three NHS hospital trusts in the northwest of England. The findings reported are part of a wider investigation into the assimilation(1) of OSN from the Philippines, India and Spain into NHS hospitals. Semi-structured interviews were undertaken with members of four groups of actors: managers, OSN, home nurses (HN) and mentors, which were analysed thematically. Results. The research confirms the finding that many OSN are prevented from using technical skills in the UK, but also suggests reasons why this is so. The finding of deskilling emerged strongly in all three cases and is singled out for discussion in this paper. CONCLUSIONS: The experience of OSN highlights ambiguity surrounding the role of the nurse in British hospitals. This arises partly because OSN tend to be recruited to the bottom grades of nursing in the NHS, where their technical skills are underused. RELEVANCE TO CLINICAL PRACTICE: Segmentation within the nursing hierarchy contributes to the conflicting messages and mismatch of expectations experienced by nurses at the ward level, regarding the role of the nurse. [ABSTRACT FROM AUTHOR]

Aims and objectives. This paper explores the perceptions of career progression in the NHS of a group of midwives and nurses trained in Ghana and working in the UK. It draws on semi-structured interviews with nurses, midwives and managers which were conducted as part of the Researching Equal Opportunities for Overseas trained Health Professionals project (REOH). Background. Research into overseas nurses in the UK has tended to focus on their experiences of discrimination in relationships with colleagues, managers and patients. There is limited statistical evidence indicating that migrant nurses experience slower career progression than their UK-trained counterparts. However, there is little analysis of their experiences and perceptions of the process of career progression or their understandings of the factors that could account for their limited entry into higher grades. Conclusions. This paper argues that many Ghanaian nurses and midwives can experience difficulty in progressing into senior positions because of cultural differences and gaps in knowledge. However, this paper indicates that these problems can become institutionalized and entrenched by practices on the ward, particularly support from managers being dispensed as patronage that is not given equally to all. This creates an informal system of promotion to management which is not transparent, is based on subjective and culturally specific criteria and can undermine egalitarian formal procedures and create spaces where discriminatory practices can operate. Relevance to clinical practice. These processes can lead to sectors of the workforce becoming demoralized, to the wastage of skills and other resources and problems in staff retention. [ABSTRACT FROM AUTHOR]

This paper reviews previous cost studies of overweight and obesity in the UK. It proposes a method for estimating the economic and health costs of overweight and obesity in the UK which could also be used in other countries. Costs of obesity studies were identified via a systematic search of electronic databases. Information from the WHO Burden of Disease Project was used to calculate the mortality and morbidity cost of overweight and obesity. Population attributable fractions for diseases attributable to overweight and obesity were applied to National Health Service (NHS) cost data to estimate direct financial costs. We estimate the direct cost of overweight and obesity to the NHS at £3.2 billion. Other estimates of the cost of obesity range between £480 million in 1998 and £1.1 billion in 2004 [Correction added after online publication 11 June 2007: ‘of the cost of obesity’ added after ‘Other estimates’]. There is wide variation in methods and estimates for the cost of overweight and obesity to the health systems of developed countries. The method presented here could be used to calculate the costs of overweight and obesity in other countries. Public health initiatives are required to address the increasing prevalence of overweight and obesity and reduce associated healthcare costs. [ABSTRACT FROM AUTHOR]

This paper explores the early implementation of an organizational innovation in the UK National Health Service (NHS) – Treatment Centres (TCs) – designed to dramatically reduce waiting lists for elective care. The paper draws on case studies of 8 TCs (each at varying stages of their development) and aims to explore how meanings about TCs are created and evolve, and how these meanings impact upon the development of the organizational innovation. Research on organizational meanings needs to take greater account of the fact that modern organizations like the NHS are complex multi-level phenomena, comprising layers of interlacing networks. To understand the pace, direction and impact of organizational innovation and change we need to study the interconnections between meanings across different organizational levels. The data presented in this paper show how the apparently simple, relatively unformed, concept of a TC framed by central government is translated and transmuted by subsequent layers in the health service administration, and by players in local health economies, and, ultimately, in the TCs themselves, picking up new rationales, meanings and significance as it goes along. The developmental histories of TCs reveal a range of significant re-workings of macro policy with the result that there is considerable diversity and variation between local TC schemes. The picture is of important disconnections between meanings, that in many ways mirror Weick's (1976) ’loosely coupled systems’. The emergent meanings and the direction of micro-level development of TCs appear more strongly determined by interactions within the local TC environment, notably between what we identify as groups of ’idealists’, ’pragmatists’, ’opportunists’ and ’sceptics’ than by the framing (Goffman 1974) provided by macro and meso organizational levels. While this illustrates the limitations of top down and policy-driven attempts at change, and highlights the crucial importance of the front-line local ’micro-systems’ (Donaldson and Mohr 2000) in the overall scheme of implementing organizational innovations, the space or headroom provided by frames at the macro and meso levels can enable local change, albeit at variable speed and with uncertain outcomes. [ABSTRACT FROM AUTHOR]

Abstract Aims: To assess the awareness and use of NHSnet within general practice. To investigate the presence of skills necessary to maximize the benefits of NHSnet connections. Methods: Postal survey of general practice staff in the Northern and Yorkshire Region. Results: At least one completed questionnaire was obtained from 65% of the general practices surveyed, and the individual response rate to the general practice survey was 44%. Ninety per cent of all respondents reported that their practice was connected to the NHSnet, with 59% of respondents reporting that they use NHSnet at least once a week. Although NHSnet was used to search for research information or guidance, all respondents in this survey still reported greater access to and use of paper-based information resources. Respondents indicated that they still needed further training on how to use NHSnet (42%), how to search the Internet (31%) and how to search electronic databases such as medline (49%). Conclusions: Since our 1999 survey, reported NHSnet connectivity has increased greatly, with a majority of respondents reporting that they use NHSnet at least once a week. Although encouraging, this level of usage suggests that using the Internet/NHSnet to find research has yet to become a core activity in general practice. [ABSTRACT FROM AUTHOR]

This paper describes an empirical study, conducted in three acute hospitals, of the attitudes of central managers, medical managers and clinicians towards the adoption of benchmarking. Benchmarking was portrayed in The New NHS White Paper (1997) as an important means of improving efficiency over the next decade. The present paper examines the context of change and nature of benchmarking. Findings are presented in seven sections including: the understanding which respondents had of benchmarking; their willingness to be involved in benchmarking; the existence of strategies and policies for implementing benchmarking; the relevance of existing costing information; and the role of networks in facilitating benchmarking. The study concludes that the process of change adopted contradicted most of the factors associated with creating receptivity to change. Also, that the publication of the National Reference Costs seemed to have more relevance to resource planning at central National Health Service Management Executive level, than to effecting improvements at operational level in acute hospitals. [ABSTRACT FROM AUTHOR]

Aims and objectives This article considers evidence regarding lay involvement in the NHS, following the White Paper’s commitment to rebuild public confidence in an NHS ‘accountable to patients and open to the public and shaped by their views’. It looks at two aspects of lay involvement: the lay board member’s involvement in primary care group (PCG) decision-making and the engagement of the PCG with the wider public. Methods The paper analyses data from the first sweep of the annual Tracker Survey of a sample of PCGs in England, led by the National Primary Care Research and Development Centre in collaboration with the King’s Fund between September and December 1999. It draws specifically from the postal questionnaires sent to lay members. Firstly, however, it contextualizes this data by reviewing the history of lay involvement before 1997 in the NHS and particularly in primary care. Conclusions The paper concludes that, during the first 6 months of their operation, the lay voice was faintly heard in PCGs. The lay member’s role in decision-making at board-level was peripheral. The majority rated their involvement in key aspects of decision-making as low and their influence on decision-making below that of other board members including the Chief Officer, the chair and the GP board members. Beyond the arena of the board, what little contact there was with the lay voice has taken the shape of informing rather than consulting. Mitigating factors include the early stage at which the survey was completed and the lack of precedents for lay involvement in primary care in a broad sense on which PCGs can draw. [ABSTRACT FROM AUTHOR]

The scheduling of nursing time on hospital wards is critical to the delivery of patient care, resource utilization and employee satisfaction. Over the past decade many hospital wards in the United Kingdom (UK) have moved away from the traditional planning of rosters by a single manager, towards more participative processes known as self-rostering and team rostering. This paper tests the hypothesis, developed from the literature, that the three types of rostering approach may be positioned along a continuum. Self-rostering at one extreme, is conducive to staff empowerment, motivation and roster effectiveness, whilst departmental rostering, at the other, leads to perceived autocracy, reduced empowerment, lower levels of staff motivation and roster effectiveness. Team rostering is positioned mid-way on this continuum. This paper reports the findings of an empirical study of nurse rostering practices in the UK National Health Service (NHS), with a view to developing an understanding of the implications of implementing these three rostering approaches and testing the above hypothesis. The survey of rostering practices in 50 NHS wards, and in-depth case studies of seven wards, revealed that each of the three rostering approaches has benefits and limitations and a picture emerges quite different from that implied by the research hypothesis. Whilst the literature suggests that the choice of rostering approach determines the level of perceived autocracy, staff motivation and roster effectiveness, it is proposed in this paper that selection of rostering approach should be contingent upon operational context. The paper concludes with a framework which stipulates that the choice of rostering approach for a ward should be determined on the basis of four contingent variables, namely, ward size, demand variability, demand predictability, and complexity of skill mix. It is recommended that departmental rostering be applied in large wards with complex rostering problems, whilst team rostering is more appropriate for medium sized wards, and self-rostering appropriate for small wards. [ABSTRACT FROM AUTHOR]

The National Institute for Health Research (NIHR) aims to improve national 'health and wealth' by providing infrastructural support to enable clinical research in National Health Service settings in England and Wales. Cognisant of the consequences of studies' failure to achieve required numbers of participants, it also actively campaigns to promote patient awareness of research, and willingness to participate in trials. In this paper, we analyse recent NIHR campaigns and policies designed to encourage patients to participate in clinical research to interrogate how they are implicated in the national bioeconomy. In doing so we expand the notion of 'clinical labour' to include the work of patient recruitment and highlight an emergent obligation on patients to contribute to research processes. Whereas once patient knowledge and experience may have been devalued, here we draw on the concept of 'assetisation' (Birch 2012) to explore the emergent relationship between healthcare system and patient as research participant. We consider how patients' contribution goes beyond the provision of standardised objects of valuation so that patients themselves may be perceived as assets to, not only recipients of, the national healthcare system. [ABSTRACT FROM AUTHOR]

This paper presents the findings of deconstructing a short extract from a report written by a National Health Service Trust chief executive. Changes in National Health Service management since the early 1980s are briefly discussed. This is followed by a theoretical discussion of deconstruction and metaphorization. The text is analysed focusing on the 'binary opposites' reason and emotion. It is argued that reason is given hierarchical pre-eminence and that emotion is hidden or marginalized but that both concepts are central in order to arrive at an understanding of the text. The chief executive appears to constitute his role in ways which might be characterized as engineering (reason) and as traditional fatherhood (emotion). Metaphors in the text are used in order to provide evidence to support these characterizations. One implication which is particularly highlighted is that management in this text is seen as a distinctively masculine practice – perhaps surprisingly within what is presumed to be the caring and supportive environment of a health care organization. The paper ends with some reflexive reflections on the analysis. [ABSTRACT FROM AUTHOR]

This paper develops a framework of empowerment within which to examine the commissioning process for nurse education arising from market reform of the British National Health Service (NHS). The paper argues that an imbalance in this commissioning process favours theoretical products, such as the diploma-level nursing curricula (Project 2000). Also, the university setting of nurse education is seen as clinically de-skilling both nurse teachers and student nurses as well as influencing the discourses on clinical skills. The paper further argues that the effects of such trends are a captive market in nurse education contracting and a displacement of nursing knowledge. An approach to commissioning nurse education is described which may counter such trends and positively impact on NHS organizational development and quality. Further reform of the commissioning process is described in context of pragmatic health legislation. [ABSTRACT FROM AUTHOR]

This paper offers an interpretation of contemporary developments in Britain's National Health Service which suggests that a major transformation is under way, the contours of which, while visible, are not yet fully appreciated or understood. The analysis is in sharp contrast with that recently proposed by Klein and deliberate comparisons are drawn. The paper is in three main sections. The first briefly summarises Klein's position. The second takes issue with certain of his views, notably those on structural change, but also to some extent those on the relevance of the private sector. Welfare pluralism is posited as the most plausible future for health care and as a phenomenon as yet not well understood in Britain's health care sector. [ABSTRACT FROM AUTHOR]

This article discusses the operation of the new freedom of information laws in Great Britain. Issues involving the basis of balancing test of the public interest. Introduction of its new code of practice on open government. Secrecy cases will bring in a new constituency, journalists, pressure groups, corporate interests and trade unions. Need for single tribunal to hear both environmental and health and safety access disputes. Government is proposing to extend the regime described above to local government and to the National Health Service.

This paper concerns two practices, public consultation and user involvement, whose adoption has been urged upon the UK National Health Service in recent years. Public consultation is a local attempt to seek the views of a broad constituency of persons. User involvement is a local attempt to include organized groups of service users in the planning, and occasionally the management, of such services. The paper has four objectives. First, it locates the topic in the context of several related current debates. Second, it outlines the main findings of a recent empirical study of public consultation as they relate to the above debates. Third, it summarizes the relevant findings of an empirical study of user involvement. Finally, it examines these two practices as "technologies of legitimation" which can be seen as a means by which managerial legitimacy is maintained in the context of an increasingly pluralistic policy arena. [ABSTRACT FROM AUTHOR]

Primary nursing is a relatively new phenomenon in the organization of ward-based nursing. This paper seeks to answer the question of what lies behind primary nursing's sudden and startling rise in popularity. Factors within nursing which are implicated include most importantly the adoption of the nursing process, and the attempt to provide truly individualized patient care. Nursing's search for professional status has played its part, primary nursing frequently being seen as a key strategy in its achievement. Other areas of wider social change have also had an impact, from the nascent dominance of new right political/social values, to the micropolitical scene within the British National Health Service. While appearing to be the ideal answer to some of nursing's current problems, primary nursing contains some inherent contradictions, most evident being those surrounding the concept of accountability. It may also threaten the cohesiveness of the nursing team on the ward, and may lead to the uncovering of conflicts between doctors and nurses. Finally, perhaps one of the major reasons for its continuing success is the way it brings together the various nursing interest groups and current managerialism in the NHS. [ABSTRACT FROM AUTHOR]

Despite the fact that the speciality of obstetrics is considered to be a high risk area, indeed it is estimated that in the UK, maternity services account for massive 60% of all the NHS litigation claims burden; scholarly activity in childbirth performance as part of the risk society is relatively underdeveloped when compared to other areas of health. It is the extent of the influence of risk upon the maternity services that makes this underdevelopment especially striking. In an effort to present childbirth as a worthwhile site for empirical investigation and theoretical discussion, this paper attempts to review the sociology of childbirth and to consolidate some of the multidisciplinary contributions made to date on childbirth within the risk society. [ABSTRACT FROM AUTHOR]

Introduction: Increased moderate to vigorous physical activity (MVPA) can improve clinical and psychosocial outcomes for people living with and beyond cancer (LWBC). This study aimed to assess the feasibility and acceptability of trial procedures in a pilot randomised controlled trial (RCT) of a theory‐driven app‐based intervention with behavioural support focused on promoting brisk walking (a form of MVPA) in people LWBC (APPROACH). Methods: Participants diagnosed with breast, prostate or colorectal cancer were recruited from a single UK hospital site. Assessments at baseline and 3 months included online questionnaires, device‐measured brisk walking (activPAL accelerometer) and self‐reported weight and height. Participants were randomised to intervention or control (care as usual). The intervention comprised a non‐cancer‐specific app to promote brisk walking (National Health Service 'Active 10') augmented with print information about habit formation, a walking planner and two behavioural support telephone calls. Feasibility and acceptability of trial procedures were explored. Initial estimates for physical activity informed a power calculation for a phase III RCT. A preliminary health economics analysis was conducted. Results: Of those medically eligible, 369/577 (64%) were willing to answer further eligibility questions and 90/148 (61%) of those eligible were enrolled. Feasibility outcomes, including retention (97%), assessment completion rates (>86%) and app download rates in the intervention group (96%), suggest that the trial procedures are acceptable and that the intervention is feasible. The phase III RCT will require 472 participants to be randomised. As expected, the preliminary health economic analyses indicate a high level of uncertainty around the cost‐effectiveness of the intervention. Conclusions: This pilot study demonstrates that a large trial of the brisk walking intervention with behavioural support is both feasible and acceptable to people LWBC. The results support progression onto a confirmatory phase III trial to determine the efficacy and cost‐effectiveness of the intervention. [ABSTRACT FROM AUTHOR]

ABSTRACT The European Union Framework Package 7 project POINT (Policy Influence of Indicators) is exploring the use of indicators in several domains (most specifically sustainable development) to see how their value and ultimate usefulness can be maximized. One key aspect of POINT is to assess the ways in which groups and communities work to make the greatest use of information. Using an innovative methodology called 'Triple Task', the authors are applying a three-cornered approach to gain an understanding of how groups work, how they assesses themselves and how they appear to function from an external perspective. In this paper, the first stage of Triple Task is described and explored. Task One is effectively a 'soft' means for a group to work together on problem identification and action planning, and the key to this is the device known as the Rich Picture. Rich Pictures have been used in group work for over 30 years, primarily as a means for the group to express its preliminary vision concerning a matter of common concern, but so far they have not been applied as a means to explore the conscious and unconscious workings of a group nor have they been assessed in terms of their content and 'message'. By understanding the group mind as represented in a picture the authors begin to gain a deeper understanding of the group's own potential to use and exploit information of all kinds and to move towards a deeper 'Sustainable Group Mind', and a more focused means to problem solve. Copyright © 2010 John Wiley & Sons, Ltd and ERP Environment. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented on topics including abuse of women and their children during post-separation contact; post-separation co-parenting from fathers; and history of domestic violence.

There has been considerable momentum within the NHS over the last 10 years to develop greater patient and public involvement (PPI). This commitment has been reflected in numerous policy initiatives. In patient safety, the drive to increase involvement has increasingly been seen as an important way of building a safety culture. Evidence suggests, however, that progress has been slow and even more variable than in health care generally. Given this context, the paper analyses some of the key underlying drivers for involvement in the wider context of health and social care and makes some suggestions on what lessons can be learned for developing the PPI agenda in patient safety. To develop PPI further, it is argued that a greater understanding is needed of the contested nature of involvement in patient safety and how this has similarities to the emergence of user involvement in other parts of the public services. This understanding has led to the development of a range of critical theories to guide involvement that also make more explicit the underlying factors that support and hinder involvement processes, often related to power inequities and control. Achieving greater PPI in patient safety is therefore seen to require a more critical framework for understanding processes of involvement that can also help guide and evaluate involvement practices. [ABSTRACT FROM AUTHOR]

Much as it is the prevailing paradigm within the NHS and the ideology underpinning the outcome measurement agenda, psychotherapy continues to question whether the evidence-based model represents a suitable methodology for complex psychological processes. Outcome measurement is antithesis to the psychotherapeutic project - or at least many within the discipline continue to argue this position. However, if providers of psychotherapy services are to survive in the 'real' world of evidence-based medicine, then the onus is upon them to side-step the 'paradigm wars' and find new ways of engaging with the mandate to measure. This paper proposes that psychotherapists can engage meaningfully with outcome measurement by asking two important questions of the time they spend with their patients: 'Is this treatment working for this individual presentation?' and, if not: 'What immediate action can be taken in order to remedy the situation?' The paper goes on to illustrate how the patient-reported outcome measure ( PROM), when incorporated into routine clinical practice can act as the mediator of this important self-evaluative process. [ABSTRACT FROM AUTHOR]

Accessible Summary The NHS Constitution states that all patients should have opportunity to take part in approved research, This study asked clinical researchers how they include people with intellectual disabilities and/or autism in research, Many barriers were identified that relate to making mental capacity judgements, Many researchers agreed new resources that support consent and capacity judgements for research would be helpful and gave some ideas about what could help, . Abstract Background Adults with intellectual disabilities and/or autism are often excluded from participating in health and healthcare research. Understanding study information, which is an important aspect of demonstrating capacity to give informed consent, can be a particular challenge. This study surveyed clinical researchers to discover: (i) their experiences of assessing mental capacity for research; (ii) what methods they used to facilitate the inclusion of adults with intellectual disabilities and/or autism; and (iii) their views about a proposal to develop new resources to facilitate mental capacity judgements with adults with intellectual disabilities and/or autism for informed consent for research. Methods Clinical researchers in North East England who conduct research with NHS patients with intellectual disabilities and/or autism were invited to participate in a 22-item self-completed semi-structured questionnaire survey, either online or on paper. Results Twenty-one clinicians completed the survey (response rate 30.4%). Participants reported on 18 research studies which included people with intellectual disabilities and/or autism. In many studies people who lacked capacity to give informed consent were excluded, and often shortcuts were taken in judging capacity. Limited adaptations to support capacity were used. Respondents welcomed the proposal of developing assistive resources that could support capacity judgements and informed consent to research. Conclusions To improve access to research for people with intellectual disabilities and/or autism, researchers need robust methods to facilitate informed consent and mental capacity judgements. Future research should determine which assistive resources show potential to support informed consent and capacity decisions, and whether such resources could improve inclusion in research. [ABSTRACT FROM AUTHOR]

Health care in England is predominantly provided free at the point of service through the publicly-funded National Health Service (NHS). Total NHS expenditure, which has risen in real terms by an average of 3.7 per cent per annum since the inception of the NHS in 1948, constituted 7.9 per cent of GDP in 2012. This paper presents a summary of the trends in medical expenditure in England together with, using detailed administrative data, an analysis of the growth over 15 years of expenditure and activity in hospital inpatient health care, which represents around 20-25 per cent of all NHS expenditure. We document the coincidence of observed trends in expenditure with reported activity, morbidity and the proximity of individuals to death. We find that: (i) expenditure for both elective and emergency inpatient care broadly follows activity, so that expenditure is mostly driven by activity rather than unit costs; (ii) expenditure is concentrated in individuals with multiple diseases, so that the prevalence and identification of complex medical conditions are important drivers of expenditure; and (iii) health care activity rises substantially for individuals in the period before death, so that expenditure is driven substantially by mortality in the population. Taken together, these findings indicate that this element of health care expenditure in England has been substantially driven by the underlying morbidity and age of the population in conjunction with improving health care technology. [ABSTRACT FROM AUTHOR]

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

Please cite this paper as: Crouch N, Deans R, Michala L-M, Liao L, Creighton S. Clinical characteristics of well women seeking labial reduction surgery: a prospective study. BJOG 2011;118:1507-1510. Objective To assess clinical characteristics and expectations in well women requesting elective labial reduction surgery. Design Prospective study of women attending an outpatient gynaecology clinic. Setting General gynaecology clinic at a Central London teaching hospital. Sample Women requesting labial reduction surgery and referred by their general practitioner. Methods The labia minora width and length were measured for all participants for comparison with published normal values. The presenting complaint was recorded, along with demographic details, expectations of surgery and sources of information regarding appearance of the labia. Main outcome measures Labial measurements, reported symptoms and expectations of surgery. Results The labia of all participants were within normal published limits, with a mean (SD) of 26.9 (12.8) mm (right labia), and 24.8 (13.1) mm (left labia). The majority of complaints were regarding appearance or discomfort. Expectations were to alter the appearance with surgery. Conclusions All women seeking surgery had normal-sized labia minora. Clear guidance is needed for clinicians on how best to care for the worried well woman seeking surgery. [ABSTRACT FROM AUTHOR]

The strategy for NHS modernization in England is privileging individual choice over collective voice in the governance of healthcare. This paper explores the tension between economic and democratic strands in the current reform agenda, drawing on sociological conceptions of embeddedness and on theories of reflexive governance. Building on a Polanyian account of the disembedding effects of the increasing commercialization of health services, we consider the prospects for re-embedding economic relationships in this field. An analysis is provided of the limits of the present legal and regulatory framework of Patient and Public Involvement (PPI) in establishing the democratic and pragmatist conditions of social learning necessary for effective embedding. We show how the attainment of reflexive governance in the public interest is dependent on such conditions, and on the capacities of patients and the public to contribute to debate and deliberation in decision making, including on fundamental policy questions such as how services are provided and by whom. [ABSTRACT FROM AUTHOR]