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In response to the commentary(1) in this month's Canadian Geriatrics Journal by Andrew and Rockwood on the recent paper I co-wrote with King's Fund colleagues--"Making Health and Care Systems Fit for an Ageing Population"(2)--I wanted to pen a very personal response, not least because of my visits to health systems in Ontario and Alberta and conversations with many Canadian colleagues that are fresh in my mind. The paper was certainly the most important and influential thing I have written, and was an attempt to weave all the elements of good practice in health care for older people into one overarching narrative. Whilst its biggest target audience is UK health services, I hope it has some relevance to Canada and might stimulate some constructive conversations. [ABSTRACT FROM AUTHOR]

This paper discusses the UK Government's public consultation into the NHS bursary and the response from the Nursing and Midwifery Council. A public consultation stipulated that the current arrangements for funding, by the State, were not to be considered for discussion. Instead, the consultation only appraised views that would lead to the successful introduction of student finance loans for NHS professional education. Testimonies from nurses, midwives and nursing students expressed concern that the new funding arrangements were unaffordable, dis-incentivising and biased towards the marketisation of student loans in the UK, yet the changes went ahead. The changes to NHS bursary funding resulted from the UK Government's desire for growth in student numbers (and ostensibly not growth in financial figures), and the fact that nursing (and other healthcare) students will become more fiscally indebted, despite society's moral obligation to them. [ABSTRACT FROM AUTHOR]

Since 2008, health policy in England has been focusing increasingly on improving quality in healthcare services. To ensure quality improvements in community nursing, providers are required to meet several quality targets, including an incentive scheme known as Commissioning for Quality and Innovation (CQUIN). This paper reports on a study of how financial incentives are used in district nursing, an area of care which is particularly difficult to measure and monitor. [ABSTRACT FROM AUTHOR]

Background: There are many challenges in delivering and evaluating knowledge for healthcare, but the lack of clear routes from knowledge to practice is a root cause of failures in safety within healthcare. Various types and sources of knowledge are relevant at different levels within the healthcare system. These need to be delivered in a timely way that is useful and actionable for those providing services or developing policies. How knowledge is taken up and used through networks and relationships, and the difficulties in attributing change to knowledge-based interventions, present challenges to understanding how knowledge into action (K2A) work influences healthcare outcomes. This makes it difficult to demonstrate the importance of K2A work, and harness support for its development and resourcing. This paper presents the results from a project commissioned by NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS) to create an evaluation framework to help understand the NHS Scotland Knowledge into Action model.Methods: The team took a developmental approach to creating an evaluation framework that would be useful and practical. This included a literature review to ensure the evaluation was evidence-based; adaptation of contribution analysis for K2A project; action research with K2A project leads to refine the work and develop suitable measures.Results: Principles for evaluation and an evaluation framework based on contribution analysis were developed and implemented on a trial project. An outcomes chain was developed for the K2A programme and specific projects. This was used to design, collect and collate evidence of the K2A intervention. Data collected routinely by the intervention was supplemented with specific feedback measures from K2A project users.Conclusions: The evaluation approach allowed for scrutiny of both processes and outcomes and was adaptable to projects on different scales. This framework has proved useful as a planning, reflecting and evaluation tool for K2A, and could be more widely used to evidence the ways in which knowledge to action work helps improve healthcare outcomes. [ABSTRACT FROM AUTHOR]

Background: Dementia is a common diagnosis in older people. It is important to identify and record dementia on emergency call-outs, as it impacts on subsequent care decisions. Ambulance services are changing from paper to electronic patient records, but there are limited data on how frequently and in which sections of the electronic patient record dementia is being recorded. Aims: To audit the proportion of ambulance electronic patient records where dementia is recorded for patients aged (i) 65 and above and (ii) 75 and above, and to describe the sections in the electronic patient record in which dementia is recorded, as there is currently no standardised button or field available. Results: A total of 314,786 electronic patient records were included in the audit, over a one-year period. The proportion of attended calls with 'dementia' recorded in the electronic patient record in patients aged 65+ was 13.5%, increasing to 16.5% in patients aged 75+, which is similar to that recorded in previous literature. For patients aged 75+ conveyed to hospital, 15.2% had 'dementia' recorded in the electronic patient record, which may indicate under-recording. Recording of dementia between Clinical Commissioning Groups varied between 11.0% and 15.3%. Dementia was recorded in 16 different free-text fields, and 38.4% of records had dementia recorded in more than one field. Conclusion: This audit demonstrates high variability in both the frequency of recording dementia and also the location in the electronic patient record. To ensure consistent recording and ease of retrieval to inform patient care and handover, we propose that the electronic patient record should be modified to reflect paramedics' needs, and those of the healthcare staff who receive and act on the report. Enhanced training for paramedics in the importance and method of recording dementia is required. Future data will enable accurate monitoring of trends in conveyance, and inform justifications for alternative services and novel referral pathways. [ABSTRACT FROM AUTHOR]

Background: Clinical research has been central to the global response to COVID-19, and the United Kingdom (UK), with its research system embedded within the National Health Service (NHS), has been singled out globally for the scale and speed of its COVID-19 research response. This paper explores the impacts of COVID-19 on clinical research in an NHS Trust and how the embedded research system was adapted and repurposed to support the COVID-19 response. Methods and findings: Using a multi-method qualitative case study of a research-intensive NHS Trust in London UK, we collected data through a questionnaire (n = 170) and semi-structured interviews (n = 24) with research staff working in four areas: research governance; research leadership; research delivery; and patient and public involvement. We also observed key NHS Trust research prioritisation meetings (40 hours) and PPI activity (4.5 hours) and analysed documents produced by the Trust and national organisation relating to COVID-19 research. Data were analysed for a descriptive account of the Trust's COVID-19 research response and research staff's experiences. Data were then analysed thematically. Our analysis identifies three core themes: centralisation; pace of work; and new (temporary) work practices. By centralising research prioritisation at both national and Trust levels, halting non-COVID-19 research and redeploying research staff, an increased pace in the setup and delivery of COVID-19-related research was possible. National and Trust-level responses also led to widescale changes in working practices by adapting protocols and developing local processes to maintain and deliver research. These were effective practical solutions borne out of necessity and point to how the research system was able to adapt to the requirements of the pandemic. Conclusion: The Trust and national COVID-19 response entailed a rapid large-scale reorganisation of research staff, research infrastructures and research priorities. The Trust's local processes that enabled them to enact national policy prioritising COVID-19 research worked well, especially in managing finite resources, and also demonstrate the importance and adaptability of the research workforce. Such findings are useful as we consider how to adapt our healthcare delivery and research practices both at the national and global level for the future. However, as the pandemic continues, research leaders and policymakers must also take into account the short and long term impact of COVID-19 prioritisation on non-COVID-19 health research and the toll of the emergency response on research staff. [ABSTRACT FROM AUTHOR]

Purpose: As surgical specialties now begin the graduated return to elective activity and face-to-face clinics, this paper investigates the current head and neck outpatient practices across the United Kingdom. Methods: A cross-sectional study comprised of an online 20-item survey was distributed to members of the British Association of Head & Neck Oncologists (BAHNO). The survey was open on a web-based platform and covered topics including safety measures for patients, protective equipment for healthcare staff and protocols for the use of flexible nasendoscopy in the clinic. Results: The survey was completed by 117 participants covering 66 NHS Trusts across the UK. There was a significant reduction in face-to-face Otolaryngology, Maxillofacial and Speech and Language clinic patients when compared to pre-pandemic numbers (p < 0.0001). Risk assessments for flexible nasendoscopy were done for 69% of clinics and 58% had an established protocol. Room downtime after flexible nasendoscopy ranged from 0 to 6 h and there was a significant increase in allocated downtime after a patient had coughed/sneezed (p < 0.001). Natural ventilation existed in 36% of clinics and the majority of responders didn't know the Air Change Per Hour (ACPH) of the clinic room (77%). Where ACPH was known, it often did not match the allocated room downtime. Conclusion: There is a wide variation in outpatient activity across the United Kingdom, but adaptations are being made to try and maintain staff and patient safety. However, more can still be done by liaising with allied teams to clarify outpatient protocols. [ABSTRACT FROM AUTHOR]

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness. It is considered as an important public health issue, and prevalence of diagnosis has increased as awareness of the disease grew over the past years. Supply of specialist medical experts has not kept pace with the increasing demand for assessment, both due to financial pressures on health systems and the difficulty to train new experts, resulting in growing waiting lists. Patients are not being treated quickly enough causing problems in other areas of health systems (e.g. increased GP visits, increased risk of self-harm and accidents) and more broadly (e.g. time off work, relationship problems). Advances in machine learning make it possible to attempt to diagnose ADHD based on the analysis of relevant data, and this could inform clinical practice. This paper reports on findings related to the mental health services of a specialist Trust within the UK's National Health Service (NHS). The analysis studied data of adult patients who underwent diagnosis over the past few years, and developed a diagnostic model for ADHD in adults. The results demonstrate that it is indeed possible to correctly diagnose ADHD patients with promising statistical accuracy. [ABSTRACT FROM AUTHOR]

Background The NHS Five Year Forward View identifies a range of approaches for addressing the NHS's challenges. The Transition movement helps communities to reframe and rebuild their world by working on issues such as climate change, food, community relationships and localizing the economy. Methods This paper describes Transition using five short example projects and, informed by these, identifies mechanisms by which Transition could potentially help reduce pressure on the NHS. Results Transition is characterized by people self-organizing to address local challenges with benefits arising from both the outcomes and the process of the projects. Transition may be able to help the NHS reframe change, prevent disease, improve staff well-being and increase local economic resilience. Discussion The evidence base for the relationship between Transition and health is growing but is not yet well developed. This reflects the complexity of establishing an evidence base for wider determinants of health. There is substantial potential learning for those in the NHS about change outside formal institutional structures. Conclusions Transition provides new ways of thinking and acting to develop greater 'community intelligence', which could help the NHS in the face of increasing pressures. [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]

Examines the implementation of contracts for health from a series of White Papers on National Health Service and reports on the workshops undertaken from the Health Services Management in England. Issues faced in contracting mental health services; Aims of government policy contained in the White Papers; How far the general aims of government policy can be achieved.

Editorial. Discusses the National Health Service (NHS) in the United Kingdom. Emphasis of NHS reform proposals; Responsibility of primary care groups; What was intended for primary care groups; Clarification requested by the General Medical Services Committee from the federal government.

Research has shown that women with insecure immigration statuses in the United Kingdom (UK) are more likely to register later in their pregnancy with National Health Service (NHS) maternity care providers. This late engagement with healthcare services is framed in academic debates as one of the key reasons for poor outcomes for these women and their children during and after birth. Interventions, therefore, have focused on how to remove barriers to accessing maternity care for these women. In this paper, we argue that this approach fails to account for the agency of the women adequately, which needs to be understood in the context of state harms and violence towards women with insecure immigration statuses and, in particular, their reproductive lives. We seek to shift these debates by framing this lack of early engagement with state-provided maternity services as a form of refusal that denotes an active disengagement by bordered women from intersecting structures of harm and oppression that are embedded in the UK's National Health Service, particularly through the charging regime. We argue that the politics of refusal in this case are embedded in struggles not only for border but also reproductive justice. Drawing on participant observation and data from secondary sources, we illustrate how refusal of early antenatal care opens pathways for bordered women to seek the care-ful conditions they need and want during pregnancy. [ABSTRACT FROM AUTHOR]

People with intellectual disabilities (PwID) have a bidirectional relationship with epilepsy. Nearly 25% of PwID have seizures and 30% people with epilepsy are thought to have a significant intellectual impairment. Furthermore, 70% of PwID are thought to have treatment‐resistant epilepsy. In the United Kingdom, antiseizure medications (ASMs) are the second most widely prescribed psychotropic agent for PwID. However, it is unclear what the current evidence and patterns is on current prescribing of ASMs, including when and how a case is made to withdraw them. A narrative review along with an analysis of large‐scale NHS Digital published data (2015–2020) on several aspects of ASM prescribing by general practices for PwID was undertaken. The review results and data analysis are consolidated and presented as 11 themes to provide a comprehensive overview of the study topic. Recent studies estimate that one‐third and one‐fifth of PwID are prescribed ASMs. A history of epilepsy is seen as the primary prescribing reason; however, often it is a legacy, and the indication is no longer clear. The proportion receiving ASMs continues to rise with age. This pattern of use does not correlate well with seizure onset. There are limited data on de‐prescribing ASMs in PwID. The study population heterogenicity, associated polypharmacy, multimorbidity and higher sudden unexpected death in epilepsy risks are outlined. Suggestions are made from available evidence for improving prescribing practices for PwID and seizures, and key areas for further research in this complex clinical area are outlined. [ABSTRACT FROM AUTHOR]

The NHS accounts for 5.4% of the UK's total carbon footprint, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focussing on the impact of implemented interventions. A systematic review was performed using Pubmed, OVID, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included. 675 abstracts were screened with 34 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability. This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery. • Perioperative environments use 3–6 times more energy than the hospital in general. • Paper/cardboard recycling bins in operating areas led to a 50–67% recycling rate. • Reusable items can lead to 70% reduction in waste generation. • Alcohol scrub solutions vs handwashing saves ∼930,000 L/year/hospital of water. • Dispensing propofol in 20 mL bottles instead of 50/100 mL reduces drug wastage by 90%. [ABSTRACT FROM AUTHOR]

The article focuses on the debate on the White Paper, "The New NHS--Modern--Dependable" which bears the hallmarks of pragmatism which have characterized many of the Labour Government's initiatives in Great Britain. The National Health Service (NHS) presented Prime Minister Tony Blair's government with a considerable challenge. Labour in opposition had opposed the Conservative Government's health reforms and continued to campaign against bureaucracy and yet some aspects of the reforms seemed to work. Labour had opposed GP fundholding because it seemed to increase inequity, and yet fundholding had been adopted by many doctors and more than half of the population were served by fundholding practices. Labour had promised improvements in the NHS and yet had accepted tough public spending limits. The White Paper seems to have steered the new Government through the first and second of the challenges, the third will only be addressed if the NHS is a clear winner in the Comprehensive Spending Review. The dilemma of the Conservative health reforms is tackled head on by declaring that what counts is what works. The White Paper retains many of the key features of the previous Government's reforms.

Purpose – The purpose of this paper is to explore, through a case study, and using Pawson and Tilley's notion of context-mechanism-outcome configurations, how a sectoral innovation system (SIS) for health technologies has developed. Design/methodology/approach – The case study data were collected as part of a large study that looked at technology innovation and adoption in the UK's National Health Service and were collected using an interpretive case study methodology. Primary data came from interviews and secondary data from published sources, including articles authored by members of the innovation team. Findings – The paper identifies three specific configurations of context, mechanism and outcome that were important in the case and discusses how these contribute to a broader understanding of a healthcare services SIS. Research limitations/implications – Research conducted through a single case study is open to the criticism that its findings are not generalisable but it has offered an economical way of gaining a deep description of a situation and an understanding of the contextual factors affecting a phenomenon. The paper presents a refined model for understanding SISs that though primarily rooted within the healthcare care sector has potential for application in other sectors, especially those that encompass a significant public-sector component. Practical implications – The paper's findings and conclusions have relevance to healthcare service innovation policy development. The findings will also be useful to professionals responsible for innovation projects and their support within the sector. Originality/value – The paper makes an important contribution to the understanding of a SIS for healthcare services as well as refining a general model of SISs. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to demonstrate how access to vaccination for older people in the UK can be both improved and used as a tool for healthy ageing. Design/methodology/approach – ILC-UK released a report “Adult Immunisation in the UK”, which applied a UK perspective to a 2013 Supporting Active Ageing Through Immunisation (SAATI) report on immunisation. The ILC report combined the SAATI findings with a traditional literature review, a policy review incorporating grey literature and the outcomes of a focus group discussion. This paper highlights the key findings of the ILC-UK report. Findings – Vaccination needs to be included as part of proactive strategies to promote healthy and active ageing. Initiatives need to be explored that increase the rate of delivery of vaccinations. Barriers to the vaccination of health and social care professionals working with older people need to be removed. The government should explore using psychological insights into human behaviour to improve the take-up of vaccinations amongst adults. The range of settings where older people can receive vaccination needs to be expanded. Information on the potential benefits of immunisation should be made readily available and easily accessible to older people. Practical implications – The paper calls for a structural shift in how vaccination services in the UK are organised. Social implications – The paper calls for a cultural shift in how society views immunisation and the role it has to play in the healthy ageing process. Originality/value – The paper uses new European research on immunisation and applies it to the UK's situation. [ABSTRACT FROM AUTHOR]

Background: Research nurses, midwives and allied health professionals are members of an important emergent profession delivering clinical research and, in the United Kingdom, have been the focus of considerable investment by the National Institute for Health Research (NIHR). This paper considers the experiences of research nurses, midwives and allied health professionals in relation to professional identity work, recognizing these are coproduced alongside others that they interact with (including patients, clinical staff and other research staff).Methods: Semi-structured interviews were conducted with 45 nurses, midwives and allied health professionals in the UK about their experiences of working in research delivery. Interviews were transcribed verbatim and thematically coded and analysed.Results: Our analysis highlights how research nurses, midwives and allied health professionals adjust to new roles, shift their professional identities and undertake identity work using uniforms, name badges and job titles as they negotiate complex identities.Conclusions: Research nurses, midwives and allied health professionals experience considerable challenges as they enter and transition to a research delivery role, with implications for their sense of professional identities. A change in the work that they undertake and how they are (or perceive they are) viewed by others (including clinical non-research colleagues and patients) has implications for their sense of professional and individual identity. The tensions involved extend to their views on symbols of professional identity, such as uniforms, and as they seek to articulate and demonstrate the value of their conjoined role in research and as a healthcare professional, within the unfolding landscape of health research. We embed our study findings in the context of the newly emerging clinical research practitioner workforce, which further exacerbates and complicates the role and identity complexity for nurses, midwives and allied health professionals in research delivery. [ABSTRACT FROM AUTHOR]

Background: Work stress and compassion fatigue are prevalent among healthcare staff and their negative effects on staff well-being and patient care are well-known. This paper reports on the implementation and evaluation of Schwartz Rounds® (Rounds) in UK healthcare organizations, predominantly part of the National Health Service (NHS). Rounds are one-hour, typically monthly, multidisciplinary forums during which clinical and nonclinical healthcare staff discuss the emotional and social demands of delivering patient care. The purpose of this research was to evaluate the effectiveness of Rounds attendance on the psychological distress, work engagement, compassion and self-reflection of healthcare staff.Methods: We used a pre-post control design to assess the effect of Rounds attendance across 10 UK healthcare organizations. This design was most appropriate given the voluntary nature of Rounds and ensured the study had ecological validity. Self-reported data were collected from attenders and non-attenders at baseline and at eight-months follow-up. The outcomes were psychological distress, work engagement, compassion and self-reflection.Results: During the 8 months' study duration, regular attenders (N = 51) attended Rounds on average 4 times (2-8). Attenders showed a significantly greater decrease in psychological distress (as measured with the General Health Questionnaire (GHQ)) than non-attenders (N = 233; odds ratio of 0.197; 95% confidence interval (0.047-0.823)). However, Rounds attendance had no significant effect on work engagement, compassion and self-reflection.Conclusions: Rounds attendance was linked to a 19% reduction in psychological distress adjusting for covariates. As an organization-wide intervention, Rounds thus constitute an effective, relatively low-cost intervention to assist staff in dealing with the demands of their work and to improve their well-being. [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]

Objective: The coronavirus disease 2019 pandemic resulted in the cessation of elective surgery. The continued provision of complex head and neck cancer surgery was extremely variable, with some UK centres not performing any cancer surgery. During the pandemic, Guy's and St Thomas' NHS Foundation Trust received high numbers of coronavirus disease 2019 admissions. This paper presents our experience of elective complex major head and neck cancer surgery throughout the pandemic. Methods: A head and neck cancer surgery hub was set up that provided a co-ordinated managed care pathway for cancer patients during the pandemic; the Guy's Cancer Centre provided a separate, self-enclosed coronavirus-free environment within the hospital campus. Results: Sixty-nine head and neck cancer patients were operated on in two months, and 13 patients had a microvascular free tissue transfer. Nosocomial infection with coronavirus disease 2019 was detected in two cases (3 per cent), neither required critical care unit admission. Both patients made a complete recovery and were discharged home. There were no deaths. Conclusion: Performing major head and neck surgery, including free flap surgery, is possible during the pandemic; however, significant changes to conventional practice are required to achieve desirable patient outcomes. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to re-examine the challenges facing leaders in health care, to explore the impact of these on the choices available to healthcare leaders, and to re-visit the nature of leadership in general. It identifies a distinction between care that is a set of auditable transactions and care that is also a covenant, and suggests that leadership too can be practised in these distinctively different ways. It draws on a three year learning set of senior practitioners in the NHS in England. Design/methodology/approach – This paper draws on the authors own observations over 25 years of educating and developing clinical leaders, and also on the insights of a learning set of senior NHS practitioners over a three period. Findings – The paper provides empirical insights about how both health care and leadership have changed over the last 30 years, and proposes that treating either of them as a set of auditable transactions in a market place results in dissatisfied leaders as well as practitioners, and that a covenant of both care and leadership needs to be understood and established. Research limitations/implications – Observations have been limited to the NHS in the UK although there are indications that the issues are of wider applicability. Practical implications – The paper includes implications for the behaviours of those leading health care organisations, those being led, and those influencing the context. Originality/value – This paper challenges prevailing definitions of leadership and prevailing explanations for difficulties in health care organisations. [ABSTRACT FROM AUTHOR]

Purpose – The literature on the use of Community Treatment Orders (CTOs) is primarily focused on people without intellectual disabilities. This paper aims to explore how CTOs are used in people with intellectual disability in the UK. Design/methodology/approach – An audit was conducted among Consultant Psychiatrists in intellectual disability psychiatry in Nottinghamshire Healthcare NHS Trust. Each consultant was asked to provide information on demographic data of their patients on CTOs, reasons for being on a CTO, conditions specified, patients' capacity to consent and their understanding of their CTOs. Conditions of CTOs were analysed using thematic analysis. Findings – There were 17 CTOs done for patients with intellectual disability from November 2008 to May 2011. Mean age was 38 with a range of 20-59. All patients had a mild or moderate intellectual disability. Only a small percentage of patients had a diagnosis of schizophrenia. More than 50 per cent had a diagnosis of pervasive developmental disorder (PDD). All patients had behavioural problems as a reason for being on a CTO. About one third of patients did not have any understanding of their CTOs. Themes of conditions were focused on providing a structured life to prevent relapse of the mental disorder. Originality/value – This paper highlights that CTOs are used differently in the intellectual disability population. CTOs are adapted to use for patients with behavioural challenges and PDD in an intellectual disability population. This contrasts with its common use to manage non-compliance with medication in patients with schizophrenia in the general adult population. This paper also suggests the main themes of conditions which clinicians can use when deciding on CTO conditions. [ABSTRACT FROM AUTHOR]

Purpose – The aim of this paper is to set out the role of clinical governance within the new commissioning framework. It starts by considering the historical development of clinical governance and lays out ideas for the new arrangements around the concept of the primary care home and concludes with challenging questions for the future. Design/methodology/approach – The paper draws on the author's role and experience as a senior policy maker in the UK Department of Health. Findings – If we are to fulfil the defined attributes of clinical governance the NHS needs to adopt a more reflective self-auditing leadership culture. Whether that supposition is accepted or not, a set of questions arises. Why, given for instance the gross failures of care for the frail elderly, have the principles of clinical governance not been systematically embedded? Why, given the NHS can no longer be described as poorly resourced, are clinical outcomes for many conditions lagging behind equivalent international healthcare systems? Why have the improved access and clinical outcomes of recent years been dependent on political rather than NHS leadership? And why in our publicly funded NHS is there frequently a culture of regarding patients as grateful supplicants rather than true partners to whom we should account? Clinical governance for personal, population and system care. Does this represent a coming of age? Originality/value – This article provides a contribution to the emerging policy debate around clinical governance in the new commissioned NHS, rooted in experience from both the clinical front line and the heart of national health policy making. [ABSTRACT FROM AUTHOR]

The NHS in England is an organisation undergoing substantial change. The passage of the Health and Social Care Act 2012, consolidates and builds on previous health policies and introduces further 'market-style' reforms of the NHS. One of the main aspects of these reforms is to encourage private and third sector providers to deliver NHS services. The rationale for this is to foster a more competitive market in healthcare to encourage greater efficiency and innovation. This changing healthcare environment in the English NHS sharpens the need for attention to be paid to the ethical operation of healthcare organisations. All healthcare organisations need to consider the ethical aspects of their operation, whether state or privately run. However, the changes in the type of organisations used to provide healthcare (such as commercial companies) can create new relationships and ethical tensions. This paper will chart the development of organisational ethics as a concern in applied ethics and how it arose in the USA largely owing to changes in the organisation of healthcare financing and provision. It will be argued that an analogous transition is happening in the NHS in England. The paper will conclude with suggestions for the development of organisational ethics programmes to address some of the possible ethical issues raised by this new healthcare environment that incorporates both private and public sector providers. [ABSTRACT FROM AUTHOR]

Purpose – This paper aims to examine the nature and prevalence of violence in a medium secure unit and to evaluate a personal defence training programme for staff working with mentally disordered offenders. Design/methodology/approach – The paper identifies an existing training gap associated with traditional breakaway techniques and describes a process of piloting a new educational module known as the spontaneous protection enabling accelerated response (SPEAR) system. Structured questionnaires were used to collect demographic data and analyse staff confidence and perceptions of the training module. Clinician confidence in coping with patient aggression was measured before, immediately after and at three months following participation in the new programme. Findings – A significant change in staff confidence was observed at two time scales after the training had been administered when compared with the pre-test baseline total scores. Over 90 per cent of staff either agreed or strongly agreed that training in the new personal defence module provided a credible defence against sudden episodes of high-risk violence. Originality/value – The paper describes a proposed module of training that may provide a credible tertiary strategy for those frontline clinicians currently exposed to the risk of sudden, spontaneous episodes of close proximity violence where traditional breakaway techniques are likely to be ineffective. This paper would interest managers, trainers and specialist practitioners that are involved in the preparation and delivery of violence reduction initiatives aimed at promoting safer and therapeutic services. [ABSTRACT FROM AUTHOR]

The authors assess the health care reform proposal of the new British government for the National Health Service (NHS) in 2010. Accordingly, the government aims to promote the involvement of public sector in influencing public health policy. They explain the advantage of placing public health directors and their teams in the council architecture. For comparison, the authors reference the health care reform efforts in the U.S.

The article discusses the importance of collaboration on nursing management in Great Britain. The article focuses on the significance of government-professional cooperation on the success of the field of nursing and how the discipline has been affected by the move of nursing education away from the National Health Service.

This is a time of significant change in health and care services in the UK, in which unprecedented power and responsibility are being devolved to clinicians. To enable this change to successfully take place and support clinicians and the wider workforce in this very important role we will need to further develop leadership capability within the system. Achieving this goal means working with the various professional, regulatory and educational bodies to ensure their standards and guidance align and describe leadership. To support this action and ensure this is done in a consistent way, the Secretary of State launched the Leadership Framework (LF) in June 2011. This is the first time that there has been a single agreed standard that provides a common understanding of leadership and a consistent approach to leadership development that spans all clinical professions, the educational and regulatory sectors and aligns with those in the NHS. A key component of the Leadership Framework is the Clinical Leadership Competency Framework (CLCF). The CLCF describes the leadership competences that clinicians need to become more actively involved in the planning, delivery and transformation of health services and has been agreed by all of the key regulatory, professional and educational bodies and is being widely adopted throughout healthcare. The CLCF has been adopted through consultation with a wide cross-section of staff, patients, professional bodies and academics, and with the input of all the clinical professional bodies and has the support of the chief professions officers, the professional advisory boards, the representative education bodies and the Department of Health. This paper reports on progress to embed the CLCF into the various professional, regulatory and educational standards and curricula. It builds on an earlier paper in this journal that provided us with a substantial evidence base in which to understand progress. Given that the framework, tools and resources have only been available since July 2011 the extent of embedding, high level of awareness and excellent examples of adoption are quite impressive. [ABSTRACT FROM AUTHOR]

In the National Health Service in England there are many sources of information pertaining to patient safety. This paper sets out to describe the challenge of measuring patient safety and describes the key data sources that underpin the national understanding of the area. The paper will describe how utilizing all of the available patient safety data, irrespective of the variability inherent, can ensure that practising clinicians have a better understanding of the current picture of patient safety and can fully evidence the efficacy of their improvement actions. Examples of effective triangulation of these data sources are given with acknowledgement of the challenges this can present in terms of engagement and understanding, particularly in the clinical context. Recommendations for the effective use of information in the assessment of patient safety are also provided. [ABSTRACT FROM AUTHOR]

Background: It is widely acknowledged that adverse lifestyle behaviours in the population now will place an unsustainable burden on health service resources in the future. It has been estimated that the combined cost to the NHS in Wales of overweight and obesity, alcohol and tobacco is in excess of £540 million. In the current climate of financial austerity, there can be a tendency for the case for prevention efforts to be judged on the basis of their scope for cost savings. This paper was prompted by discussion in Wales about the evidence for the cost savings from prevention and early intervention and a resulting concern that these programmes were thus being evaluated in policy terms using an incorrect metric. Following a review of the literature, this paper contributes to the discussion of the potential role that economics can play in informing decisions in this area. Discussion: This paper argues that whilst studies of the economic burden of diseases provide information about the magnitude of the problem faced, they should not be used as a means of priority setting. Similarly, studies discussing the likelihood of savings as a result of prevention programmes may be distorting the arguments for public health. Prevention spend needs to be considered purposefully, resulting in a strategic commitment to spending. The role of economics in this process is to provide evidence demonstrating that information and support can be provided cost effectively to individuals to change their lifestyles thus avoiding lifestyle related morbidity and mortality. There is growing evidence that prevention programmes represent value for money using the currently accepted techniques and decision making metrics such as those advocated by NICE. Summary: The issue here is not one of arguing that the economic evaluation of prevention and early intervention should be treated differently, although in some instances that may be appropriate, rather it is about making the case for these interventions to be treated and evaluated to the same standard. The difficulty arises when a higher standard of cost saving may be expected from prevention and public health programmes. The paper concludes that it is of vital importance that during times of budget constraints, as currently faced, the public health budgets are not eroded to fund secondary care budget shortfalls, which are more easily identifiable. To do so would diminish any possibility of reducing the future burden faced by the NHS of lifestyle-related illnesses. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to set out the Law Commission's final recommendations for the reform of adult social care, with a particular emphasis on the recommendations for a new legal framework for adult safeguarding in England and Wales.Design/methodology/approach - The paper discusses each of the Law Commission's recommendations for adult safeguarding and contrasts them with the proposals put forward at the consultation phase of the review.Findings - The paper argues that a single legal framework for adult social care, including adult safeguarding, with have substantial benefits in terms of legal clarity, consistency and efficiency.Social implications - A clear and single legal framework is important for older and disabled people, and their carers, in order to understand fully their entitlements, and for local authorities and partnership agencies (such as the NHS and the police) in order to understand fully their responsibilities.Originality/value - The paper provides a clear summary of the Law Commission's final report - in particular the recommendations for adult safeguarding. [ABSTRACT FROM AUTHOR]

Purpose – Attempts to modernise the National Health Service (NHS) in the UK involve promoting flexible approaches to work and training, restructuring postgraduate training and increasing control and scrutiny of doctors' work. However, the medical community has responded with expressed anxiety about the implications of these changes for medical professionalism and the quality of patient care. This paper aims to address these issues. Design/methodology/approach – Drawing on literature on nostalgia, gender, identity and organisations, the paper explores the narratives of 20 senior NHS hospital doctors to identify ways in which doctors use nostalgia to react to organisational and professional challenges and resist modernisation and feminisation of medicine. Findings – This paper illustrates how senior hospital doctors' nostalgic discourses of temporal commitment may be used to constitute a highly esteemed professional identity, creating a sense of personal and occupational uniqueness for senior hospital doctors, intertwined with gendered forms of othering and exclusionary practices. Practical implications – Nostalgia at first sight appears to be an innocuous social construct. However, this study illustrates the significance of nostalgia as a subversive practice of resistance with implications for women's career and identity experiences. Change initiatives that seek to tackle resistance need also to address discourses of nostalgia in the medical profession. Originality/value – The main contribution of this study is that we illustrate how supposedly neutral discourses of nostalgia may sometimes be mobilised as devices of resistance. This study questions simplistic focus on numerical representation, such as feminisation, as indicative of modernisation and highlights the significance of exploring discourses and head counts for understanding resistance to modernisation. [ABSTRACT FROM AUTHOR]

Purpose - This paper seeks to set out the Law Commission's final recommendations for the reform of adult social care, including the community care assessment process, service provision, and the recommendations for a new legal framework for adult safeguarding in England and Wales.Design/methodology/approach - The paper discusses each of the Law Commission's recommendations for adult social care and contrasts them with the proposals put forward at the consultation phase of the review.Findings - The paper argues that a single legal framework for adult social care, including adult safeguarding, will have substantial benefits in terms of legal clarity, consistency, and efficiency. A clear and single legal framework is important for older and disabled people, and their carers, in order to understand fully their entitlements, and for local authorities and partnership agencies (such as the NHS and the police) in order to fully understand their responsibilities.Originality/value - The paper provides a clear summary of the Law Commission's final report - in particular the recommendations for community care assessments and service provision and adult safeguarding. [ABSTRACT FROM AUTHOR]

Hospitals need to understand patient flows in an increasingly competitive health economy. New initiatives like Patient Choice and the Darzi Review further increase this demand. Essential to understanding patient flows are demographic and geographic profiles of health care service providers, known as 'catchment areas' and 'catchment populations'. This information helps Primary Care Trusts (PCTs) to review how their populations are accessing services, measure inequalities and commission services; likewise it assists Secondary Care Providers (SCPs) to measure and assess potential gains in market share, redesign services, evaluate admission thresholds and plan financial budgets. Unlike PCTs, SCPs do not operate within fixed geographic boundaries. Traditionally, SCPs have used administrative boundaries or arbitrary drive times to model catchment areas. Neither approach satisfactorily represents current patient flows. Furthermore, these techniques are time-consuming and can be challenging for healthcare managers to exploit. This paper presents three different approaches to define catchment areas, each more detailed than the previous method. The first approach 'First Past the Post' defines catchment areas by allocating a dominant SCP to each Census Output Area (OA). The SCP with the highest proportion of activity within each OA is considered the dominant SCP. The second approach 'Proportional Flow' allocates activity proportionally to each OA. This approach allows for cross-boundary flows to be captured in a catchment area. The third and final approach uses a gravity model to define a catchment area, which incorporates drive or travel time into the analysis. Comparing approaches helps healthcare providers to understand whether using more traditional and simplistic approaches to define catchment areas and populations achieves the same or similar results as complex mathematical modelling. This paper has demonstrated, using a case study of Manchester, that when estimating the catchment area of a planned new hospital, the extra level of detail provided by the gravity model may prove necessary. However, in virtually all other applications, the Proportional Flow method produced the optimal model for catchment populations in Manchester, based on several criteria: it produced the smallest RMS error; it addressed cross-boundary flows; the data used to create the catchment was readily available to SCPs; and it was simpler to reproduce than the gravity model method. Further work is needed to address how the Proportional Flow method can be used to reflect service redesign and handle OAs with zero or low activity. A next step should be the rolling out of the method across England and looking at further drill downs of data such as catchment by Healthcare Resource Group (HRG) rather than specialty level. [ABSTRACT FROM AUTHOR]

The article discusses the highlights of the discussion on "Resource allocation models" at a meeting of The Royal Statistical Society in 2011. The discussion tackled issues concerning the National Health Service allocation formulae for local governments in Great Britain and responses to papers presented, one by Jane Galbraith and Mervyn Stone, and one by Alex Gibson and Sheena Asthana. Speakers include Irini Moustaki, Mike Heiser and Ian Hunt.

Purpose - This paper seeks to provide an analysis of historic and current criminal injuries compensation schemes in Great Britain.Design/methodology/approach - The paper aims to explain the nature of the Criminal Injuries Compensation Authority (CICA) that administers the present scheme and to identify the qualifying criteria to establish eligibility for awards of compensation and obstacles to success. It deals with the nature and amounts of the awards available, the evidence gathering process, causes of delay and impediments to the achievement of fair outcomes. In the context of cases of serious injury, including acquired brain injury, it examines specific problems that are likely to be encountered and a perceived inadequacy of the compensation available to victims of such injury. The paper considers the involvement of the National Health Service in cases where applications for compensation are made and the possibility that medical professionals might inadvertently hinder the chances of a fair award. The position of local authorities and social services departments is also addressed, as is the danger that proper claims for injured victims might not be identified.Findings - From the point of view of the victim of crime who is faced with making an application to CICA, the problems that they face lie with the process, the possibility of being refused on technical grounds, limits on compensation, gaps in the scheme - which might leave victims or their relatives going uncompensated or under-compensated, and finally the lack of financial support with the cost of representation where it is needed. Of equal concern is the fact that the description of the circumstances of the assault and the injuries suffered can be crucial to ensure that full, proper, and relevant evidence gathering is undertaken. Without suitable skills, it is very easy for the lay applicant inadvertently to mislead, or to give the CICA the opportunity to reject or under-compensate.Originality/value - This paper provides a detailed analysis of CICA and reflects upon what the future might hold for injured victims of crime. [ABSTRACT FROM AUTHOR]

Purpose -- The purpose of this paper is to provide a viewpoint on the exercise of leadership. Design/methodology/approach -- This paper provides a view on the author's experience of exercising leadership as Leader of the Chaplaincy and Spiritual Care Department in Sheffield Health and Social Care NHS Foundation Trust (in England). Findings -- The author argues that leadership is as much intuition as science and considers how courageous leadership coupled with sound management can transform a service. A paradigm shift is proposed and its impact on various dimensions of the service is considered. Finally, but fundamentally, it is suggested that services need to re-orientate themselves radically around the hopes and aspirations of those they purport to serve. They need to start doing things with people rather than to them. Originality/value -- This viewpoint provides insights relevant to anyone leading a small team within a large organisation or exercising organisation-wide leadership. It will be particularly helpful to leaders seeking to find the answers in very turbulent times when the way ahead is far from clear. [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]

This paper explores practice development and radical policy reforms found in the White Paper Healthy lives, healthy people, which place a higher priority on UK public health by integrating services under the concept of localism. As a method to improve health and reduce health inequalities, localism aims to promote public health services to be responsive, resourced, rigorous and resilient. However, issues of evidence-based practice, staff freedom to innovate against the tensions of reforms and organisational structures are significant within primary care. By promoting local and professionally driven innovation, the experiences of one community service practice development unit are discussed as an effective approach to encourage local change and innovation. Two issues of significance to innovation in nursing practice and the effectiveness of localism are the application of evidence into practice and motivating staff against the tensions of unrelenting reforms. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to demonstrate that organisational sustainability is not a continuation of the status quo but, seen from a complexity theory perspective, is a continuous dynamic process of co-evolution with a changing environment. It is underpinned by learning, and it creates new structures and ways of working to adjust and to continue adjusting to a changing set of conditions. Design/methodology/approach - This longitudinal study concerns two London-based NHS hospitals: a teaching hospital and a District General Hospital. The analysis is based on several sets of semi-structured interviews, group interviews and workshops, conducted in June and July 2005 and again in October 2006 and finally in January 2007. The argument used to analyse narrative data is underpinned by complexity theory and based on two hypotheses and two assumptions defined in the paper. Findings - Both hospitals faced a significant deficit and in addressing it they had to change fundamentally ways of working and relationships, to become capable of learning and changing. Empirical data reveal two different styles of leadership, creating totally different "enabling environments" and illustrate some essential elements of sustainability. Leadership and the creation of an enabling environment are necessary but not sufficient, if the changes have not been embedded within the organisational culture, through a different way of working, relating and thinking. Originality/value - The paper provides theoretical insights in practice through case study exploration to emphasise that the distinctive characteristic of complex systems is their ability to create new order; that is, not simple adaptation, but in this case a different way of working, thinking and relating. A key insight is that sustainability is a continuous process of co-evolution. The paper also highlights the critical significance of leadership styles in fostering or inhibiting learning in organizations and the importance of co-creating enabling environments which facilitate learning. It further demonstrates the value of leaders understanding and working with (not constraining) their organisations as complex social systems. [ABSTRACT FROM AUTHOR]

Commentators have argued that we have entered a new era of migration described by Vertovec as a ‘transformative diversification of diversity’. Multiple variables of difference in the ethnicity, immigration status, rights and entitlements, age and gender profiles and patterns of distribution, of new migrants mean that the UK, and many other EU countries, are now home to the most diverse population ever experienced. The onset of super-diversity challenges traditional multicultural models of welfare provision originally based upon an understanding of migrants as large and geographically contained clusters of predominantly postcolonial migrants. These changes are occurring at a time when migration has become highly politicized, multiculturalism is being questioned, a shift is under way towards assimilation and welfare provision has become re-racialized. This paper argues that models of welfare provision need to be rethought to take into account the new reality of super-diversity in a way that is affordable, politically acceptable and meets the needs of all. Using data from research undertaken from studies of health service provision in the West Midlands the paper explores the challenges of meeting the needs of new migrants under existing provision, the costs of failing to adapt to super-diversity and the reasons why provision has failed to adapt. The paper concludes by arguing the need for different approaches to provision, and suggesting some new ways forward. [ABSTRACT FROM PUBLISHER]

Purpose -- The importance of networks in effecting the outcomes of change processes is well-established in the literature. Whilst extant literature focuses predominantly on the structural properties of networks, our purpose is to explore the dynamics of network emergence that give rise to the outcomes of process improvement interventions. Through the use of actor-network theory (ANT), the purpose of this paper is to explore the dynamics in the implementation of a process improvement methodology in the complex organisational setting of a UK National Health Service Trust. The paper illustrates the utility of ANT in articulating the dynamic nature of networks underpinning socio-technical change, and our analysis provides insights for the management process change initiatives. Design/methodology/approach -- This is a rich qualitative study in the Pathology Unit of a UK National Health Service Trust, using ANT as the theoretical lens for tracking the emergence and transformation of networks of individuals over the course of a management intervention to promote "Lean thinking" for process performance improvements. Findings -- ANT is useful for explicitly tracking how organisational players shift their positions and network allegiances over time, and for identifying objects and actions that are effective in engaging individuals in networks which enable transition to a Lean process. It is important to attend to the dynamics of the process of change and devise appropriate timely interventions enabling actors to shift their own positions towards a desired outcome. Research limitations/implications -- The paper makes the case for using theoretical frameworks developed outside the operations management to develop insights for designing process interventions. Originality/value -- By understanding the role of shifting networks managers can use timely interventions during the process implementation to facilitate the transition to Lean processes, e.g. using demonstrable senior leadership commitment and visual communication. [ABSTRACT FROM AUTHOR]

Despite a sizeable literature on the evolution of health insurance in Britain and Canada, there is virtually no research on the transnational migration of physicians between these countries in the immediate postwar period. This article hopes to address this neglected subject. Three inter-related topics will be examined. First, the paper will summarize the debate over physician emigration from the National Health Service (NHS) in postwar Britain. It will demonstrate how British social scientists and politicians began to come to grips with a major demographic exodus of British-trained doctors in the late 1950s and early 1960s. Second, it will analyze the changing health human resource situation in 1960s Canada, which focused, for practical and cultural reasons, on General Medical Council of Britain licensed practitioners. Third, through oral interviews of British-trained physicians who settled in Canada during the 1960s, it will examine the professional and personal reasons why physicians left Britain for Canada. It reveals that, among a myriad of personal issues that motivated a physician to leave the NHS, the inflexibility and hierarchical nature of British medicine loomed very large. The paper will conclude by reflecting on the contemporary significance of this fascinating historical phenomenon. [ABSTRACT FROM PUBLISHER]

Purpose - The purpose of this paper is to describe a recent experiment in research coproduction in an evaluation of service planning at a London Mental Health NHS Trust. The paper aims to consider whether members of the research team who have themselves been users of mental health services are able to contribute to the research process as "experts by experience", or if their experiential knowledge is "colonized" within the academic research team. Design/methodology/approach - A qualitative, comparative case study approach was adopted, using structured observations and semi-structured interviews. Researchers' reflective accounts and a reflective focus group were employed to explore the process of coproduction. Findings - The paper concludes that, far from "colonising" expertise by experience, the experiment builds local capacity in research coproduction and usefully informs a service planning process that reflects the priorities and concerns of a range of stakeholders. Research limitations/implications - The paper describes a small, local experiment in research coproduction and so findings are limited in their scope. However, the study demonstrates an effective methodological approach to evaluating, empirically, the impact of coproduction on the health services research (HSR) process. Practical implications - The paper demonstrates the potential for repeated exercises in coproduction to build capacity in collaborative approaches to both HSR and service planning. Originality/value - The involvement of experts by experience is increasingly a policy requirement in the domains of both health service planning and HSR in the UK. There are very few empirical studies that evaluate the impact of that coproduction. [ABSTRACT FROM AUTHOR]

This paper suggests a social-psychological framework for understanding the usability of mobile computers. This framework complements and extends extant sociological explanations of mobile computing. Sociological explanations satisfy principles of pragmatism and ubiquity in judging the usability of mobile computers. The paper argues that sociological explanations are inadequate, and draws upon the historical epistemology of perception to propose social-psychological explanations to complement them. By this epistemology, a user’s perception is deemed as a mode of action that is mediated by historical or functional representations. These issues are illustrated in an empirical case of the use of personal digital assistants (PDAs) in hospitals of the British National Health Service. The historical epistemology of perception suggests the principle of representation to complement the existing principles of ubiquity and pragmatism. This suggestion is derived from an analysis of the complementation between the user’s perception, work and movement which are conscious actions enacted concurrently during the use of mobile computers. Implications for the implementation and evaluation of mobile computing projects are provided. [ABSTRACT FROM AUTHOR]