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Early Intervention in Psychosis Services (EIP) offer a unique service model for people experiencing a first episode of psychosis. They are intensive case-management services which adopt an assertive outreach approach, employing flexible boundaries to meet clients in the community, and support them towards recovery and holistic goals. Current boundary theory is therefore not easily applied to this clinical context. This study aimed to explore how care-co-ordinators in EIP develop their understanding and practise around navigating boundaries. Participants were 13 EIP care co-ordinators. Semi-structured interviews with participants were conducted and analysed using grounded theory. A concentric model emerged, defining different layers of influence impacting care co-ordinators' navigation of boundaries. This included higher governing levels (e.g. professional codes of conduct), factors and challenges specific to EIP culture, client characteristics and individual care co-ordinator decision-making processes. A flexible, case-by-case approach was adopted in response to challenges. Findings suggest clinical implications for how care co-ordinators can jointly construct appropriate boundaries with clients and families, and discuss dilemmas using the team resource. This model can be used as a tool in clinical practice to aid clinicians' thinking and reflection around boundaries within EIP. [ABSTRACT FROM AUTHOR]

Introduction: Reablement services support people to regain skills and increase their independence. This aim resonates with occupational therapy philosophy. This article presents results of a study of the role of occupational therapists in reablement services that involve two organisations. Method: Theories on the role of occupational therapists in reablement were identified using a realist synthesis approach and were tested and expanded using a qualitative case study design. Each of the three case studies consisted of one reablement service in England. Methods of the study included observations and interviews with occupational therapists, interviews with managers in both organisations and focus groups and interviews with reablement support workers. Findings: Findings conclude that occupational therapists' education and experience underpin their ability to undertake assessments and person-centred goal setting. They utilise a range of intervention techniques selecting from their toolbox of interventions to support people. Occupational therapists have a role in training reablement support workers to work in an enabling way. Regular communication and co-location support levels of trust and shared purpose between members of the reablement team. Conclusion: The conceptual framework developed from the study can be used by organisations when commissioning and developing reablement services to consider the different contextual layers of reablement. [ABSTRACT FROM AUTHOR]

Introduction: There is a growing recognition of the impact of work on health both positive and negative. It is important that all health care professionals are equipped to understand the effects of work and worklessness on health and help patients remain in work or manage a healthy return to work where appropriate. Despite explicit reference to health and work in the General Medical Council's Outcomes for Graduates, currently, this is not a theme that is integrated across the undergraduate medical curricula. Aim: This study evaluates medical tutors' and undergraduates' perspectives of a selection of health and work topics in a teaching pilot to consider the suitability and appropriateness for delivery, integration into the curriculum, tailoring of the resources, and appropriateness and expected attainment of learning objectives. Methods: Qualitative, semi-structured interviews and focus groups were carried out with five medical tutors and 36 undergraduates. Interviews and focus groups were recorded, transcribed and thematically analysed. Results: Medical tutors and undergraduates identified suitability of appropriate subject specialities and years of teaching, whether learning objectives were important and if these had been achieved, and recommendations for future delivery. Discussion: Medical tutors were committed to delivering the health and work topics with the flexibility of tailoring the resources to existing subject specialities and with respect to the year of study. Learning objectives were perceived appropriate by tutors, despite ambivalence about their importance from some undergraduates. Resources were identified as having relevance to public health undergraduate teaching and during general practice placements. [ABSTRACT FROM AUTHOR]

To examine the feasibility and acceptability of NIDUS-Family, a 6–8 session manualised, individually tailored, modular intervention supporting independence at home for people with dementia; and explore participants' and facilitators' experiences of the intervention. In this single group multi-site feasibility study, trained, supervised non-clinically qualified graduates (facilitators) delivered NIDUS-Family to family carer and people living with dementia dyads. We recruited participants from GP practices and memory services in London and Bradford. We completed quantitative outcomes pre- and post-intervention; and conducted qualitative interviews with participants and facilitators. Our pre-specified main outcomes were proportion of potential participants approached who agreed to participate, intervention adherence and acceptability to family carers, and facilitator fidelity to the manual. We recruited 16 dyads (57% of those approached); 12 (75%) completed the intervention. Of 12 participants rating intervention acceptability, 9 (75%) agreed or strongly agreed that it had helped; 2 (18%) neither agreed nor disagreed and 1 (8%) disagreed. Mean facilitator fidelity was high (81.5%). Dyads set on average 3.9 goals; these most commonly related to getting out and about and increasing activity/hobby participation (n = 10); carer wellbeing (n = 6), managing physical complaints (n = 6); meal preparation/cooking (n = 5); and reducing irritability, frustration or aggression (n = 5). Almost all secondary outcomes changed in a direction indicating improvement. In our qualitative analysis we identified three overarching themes; relationships facilitate change, goal-focused versus manualised approach and balancing the needs of carers and people with dementia. NIDUS-Family was feasible and acceptable to participants. Following refinements, testing in a pragmatic trial is underway. [ABSTRACT FROM AUTHOR]

Policy driven change is challenging, with a significant gap between theory and practice. A key tension in enacting such change is achieving a balance between bottom-up development of local, context-specific approaches, and top-down, centrally determined policy solutions and their mutual sequencing. Ideal type models of the policy-making process envisage a rational ordered approach, driven by evidence and accompanied by ongoing evaluation of outcomes (Parsons, 1995, p77); however, the reality is far more complex. We examine the implementation and early operation of the New Care Models (NCM) Vanguard programme in England, using Matland's (1995) ambiguity-conflict model, to explore the aims and expectations of the programme. We consider the relationship between top-down and bottom-up approaches to policy development and draw attention to the pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid learning, scale and spread. We suggest that future programmes for large-scale policy implementation initiatives could be crafted differently to take account of the environment of implementation and render ambitions more realistic. Rather than aiming to create a set of definite products and templates, it may be that a set of principles for design and implementation should be developed and spread. [ABSTRACT FROM AUTHOR]

The Greater Manchester Community Pharmacy Care Plan (GMCPCP) service provided tailored care plans to help adults with one or more qualifying long‐term condition (hypertension, asthma, diabetes and COPD) to achieve health goals and better self‐management of their long‐term conditions. The service ran between February and December 2017. The aim of this study was to investigate the impact of the service on patient activation, as measured by the PAM measure (primary outcome). Secondary outcomes included quality of life (EQ‐5D‐5L, EQ‐VAS), medication adherence (MARS‐5), NHS resource use and costs, systolic and diastolic blood pressure, HDL cholesterol ratio levels and body mass index (BMI). A before and after design was used, with follow‐up at 6‐months. A questionnaire was distributed at follow‐up and telephone interviews with willing participants were used to investigate patient satisfaction with the service. The study was approved by the University of Manchester Research Ethics Committee. Quantitative data were analysed in SPSS v22 (IBM). A total of 382 patients were recruited to the service; 280 (73%) remained at follow‐up. Ten patients were interviewed and 43 completed the questionnaire. A total of 613 goals were set; mean of 1.7 goals per patient. Fifty percent of goals were met at follow‐up. There were significant improvements in PAM, EQ‐5D‐5L and EQ‐VAS scores and significant reductions in systolic blood pressure, BMI and HDL cholesterol ratio at follow‐up. Mean NHS service use costs were significantly lower at follow‐up; with a mean decrease per patient of £236.43 (±SD £968.47). The mean cost per patient for providing the service was £203.10, resulting in potential cost‐savings of £33.33 per patient (SD ± 874.65). Questionnaire respondents reported high levels of satisfaction with the service. This study suggests that the service is acceptable to patients and may lead to improvements in health outcomes and allows for modest cost savings. Limitations of the study included the low response rate to the patient questionnaire. [ABSTRACT FROM AUTHOR]

Integrating health and social care services remains one of the most difficult undertakings in the field of care delivery. One of the key requirements for success in integration programmes is a shared vision amongst care providers. Shared visions may contain views as to what the new services should look like, how it should operate and what it should be able to achieve. The paper reports findings of an evaluation of a service integration programme in the North of England. It confirms that a programme consensus on issues such as aims and objectives and programme logics is seen by participants as a key to success. Yet, the study also found that there is a specific window of opportunity in integration programmes when participating organisations start on relatively high levels of commitment and enthusiasm which tend to tail off relatively quickly. The paper closes with a discussion about the implications of the findings for programme designers and service planners. [ABSTRACT FROM AUTHOR]

Objectives: The paper reports on an empirical study of Health and Wellbeing Boards (HWBs) in England. Established by the Health and Social Care Act 2012, HWBs act as place-based hubs for leaders in health, social care, local government and other sectors to come together to address health improvement and the wider determinants of health. Methods: We conducted a three-year study of HWBs (2015–2017) in five localities across England. This involved collecting qualitative data from semi-structured interviews with key actors in the HWBs at strategic and operational levels, and focus group sessions with voluntary-sector participants at each HWB. Results: HWBs have largely followed the path of previous partnerships in terms of a lack of clear aims and objectives, lack of ownership and accountability by partners, and an absence of any significant impact on health outcomes. Conclusions: Many of the features of unsuccessful partnership working were largely displayed by HWBs. Boards require more executive power and ownership from the bottom up if they are to have any real impact. [ABSTRACT FROM AUTHOR]

Mild frailty is common among older people, but it is potentially reversible with health promotion interventions. Behaviour change may be a key to preventing progression of frailty; however, we know little about what interventions work best and how a behaviour change approach would be perceived by this group. The aim of this study was to explore how mildly frail older people perceive health promotion based on behaviour change and what factors affect engagement with this approach. We conducted semi‐structured interviews with 16 older people with mild frailty who received a pilot home‐based behaviour change health promotion service, including a dyad of older person/family carer, and two service providers delivering the service in two diverse areas of South England. Interviews were audio‐recorded, transcribed and thematically analysed. The concept of goal setting was acceptable to most participants, though the process of goal setting needed time and consideration. Goals on maintaining independence, monitoring of progress and receiving feedback were reported to increase motivation. Physical/mental capability and knowledge/perception of own needs were main determinants of the type of goals chosen by participants as well as the approach used by the project workers. Older people with complex needs benefited from care coordination, with a combination of goal setting and elements of social, practical and emotional support in varying proportions. Mildly frail older people responded well to a behaviour change approach to promote health and well‐being. Further consideration is needed of the most effective strategies based on complexity of needs, and how to overcome barriers among people with cognitive impairment. [ABSTRACT FROM AUTHOR]

Objectives: To assess the extent of shared decision-making within goal-setting meetings and explore patient-reported factors that influenced their participation to shared decision-making about their goals. Design: A two-phase explanatory sequential mixed-methods study, using questionnaires and interviews. Setting: A rehabilitation centre and patients' homes. Subjects: Frail elderly patients. Main Measures: Quantitative data were collected after every patient's goal-setting meeting using the Multifocal Approach to Sharing in Shared Decision Making (MAPPIN'SDM) questionnaire that assesses competencies relevant to shared decision-making. Shared decision-making was rated by an observer, patients and staff and compared. Qualitative data were collected through semi-structured interviews. Results: A total of 24 rehabilitation team members and 40 patients (mean age: 83 years) participated. All study participants felt that competency 7a (the language used by staff made sense to the patient) was observed in all meetings. Patients reported that for 22 of the meetings competency 4a, the advantages and disadvantages of rehabilitation, was not discussed. Games-Howell tests for direction of differences between groups showed significant difference (P = 0.001) between patients and staff in whether patients' problems were discussed. Nine patients' interviews suggested that motivation, self-confidence, family support, preparing themselves, getting information about goal-setting and rehabilitation options could enable them to participate in shared decision-making. They suggested that staff should communicate clearly and demonstrate that they are listening to patients but without a paternalistic approach. Conclusion: Staff exhibited most shared decision-making competencies at a good level. However, patients highlighted problems with information sharing and felt staff might not be listening to them. Research and practice should explore tools to address these shortfalls. [ABSTRACT FROM AUTHOR]

Personalisation of social care for adults is a key policy objective in the United Kingdom (UK), as in many other welfare states, having gained wide acceptance as essential for the empowerment of service users and as a means of managing increasing population demand. The system of personal budgets being established in the UK pursues twin objectives: aiming to ‘empower’ individuals to achieve ‘more for less’. However, there is mixed evidence that either objective is being achieved in practice. This is especially so in respect of older people who are less likely to accept a personal budget and more likely to be dissatisfied with their experience of using one. A qualitative study of eight cases in two local authority areas in England explored older people's experience of using a personal budget taken in the form of a direct payment. Data were elicited through a series of three in-depth interviews with each participant. The study was concerned with understanding the relationship between participants' experience of ‘Self’ and personalised services. Participants experienced personalisation when paid carers perceived and accommodated their ‘special requirements of Self’. In most cases this was achieved despite the consumerist aspects of personalisation rather than because of them, and often gave rise to risk and dilemma. The findings emphasise the importance of holistic assessment, and commissioning for quality over maximising choice. [ABSTRACT FROM PUBLISHER]

Objective: To explore whether goal-setting for rehabilitation with acute stroke survivors is patient-centred and identify factors which influence the adoption of patient-centredness in goal-setting practice. Setting: Acute stroke unit in a large teaching hospital in England. Participants: Patients with stroke who had no cognitive or significant communication problems and health care professionals who had a significant engagement with an individual patient were approached for participation. Method: Multiple qualitative methods were used. Perceptions and beliefs about patient-centredness, within the context of goal-setting, were collected from patients and corresponding professionals using qualitative semi-structured interviews. Adoption of patient-centred behaviour was triangulated using analysis of patient records and observation of team meetings related to participating patients. Data analysis: Interview transcripts and field notes were coded, clustered under categories and descriptively summarised. Additionally, data from patients’ documents were summarised. These summaries were then mapped on to an a-priori frame work of patient-centredness from which further interpretative themes were derived. Results: Seven patients and seven health-care professionals participated. Goal-setting was not consistently patient-centred as evidenced by a) incongruities between patients and professionals in setting, communicating and prioritising of goals and b) dysfunctional therapeutic relationships. The factors that influenced patient-centred goal-setting were both professional and patient beliefs and attributes, work-culture, practice model, limitations in knowledge and systems that disempowered both professionals and patients. Conclusion: It may be possible to infer that current local practice of goal-setting was inadequately patient-centred. Further research is required to identify strategies to overcome these challenges and to develop patient-centred goal-setting methods. [ABSTRACT FROM AUTHOR]

Football can bring people together in acts of solidarity and togetherness. This spirit is most evocatively illustrated in the world renowned football anthem 'You'll Never Walk Alone' (YNWA). In this paper, we argue that this spirit can be effectively harnessed in nursing and mental health care. We draw on data from qualitative interviews undertaken as part of evaluating a football and mental health project to explore the nature of supportive social relations therein. We use some of the lyrics from YNWA as a metaphor to frame our thematic analysis. We are especially interested in the interactions between the group facilitators and group members, but also address aspects of peer support within the groups. A contrast is drawn between the flexible interpersonal boundaries and self-disclosure evident in the football initiative, and the reported, more-distant relations with practitioners in mainstream mental health services. The findings suggest scope for utilizing more collective, solidarity-enhancing initiatives and attention to alliances and boundaries to maximize engagement and therapeutic benefits within routine practice. [ABSTRACT FROM AUTHOR]

Reflective practice is used increasingly to enhance team functioning and service effectiveness; however, there is little evidence of its use in interdisciplinary teams. This paper presents the qualitative evaluation of the Interdisciplinary Management Tool ( IMT), an evidence-based change tool designed to enhance interdisciplinary teamwork through structured team reflection. The IMT incorporates three components: an evidence-based resource guide; a reflective implementation framework based on Structured, Facilitated Action Research for Implementation methodology; and formative and summative evaluation components. The IMT was implemented with intermediate care teams supported by independent facilitators in England. Each intervention lasted 6 months and was evaluated over a 12-month period. Data sources include interviews, a focus group with facilitators, questionnaires completed by team members and documentary feedback from structured team reports. Data were analysed qualitatively using the Framework approach. The IMT was implemented with 10 teams, including 253 staff from more than 10 different disciplines. Team challenges included lack of clear vision; communication issues; limited career progression opportunities; inefficient resource use; need for role clarity and service development. The IMT successfully engaged staff in the change process, and resulted in teams developing creative strategies to address the issues identified. Participants valued dedicated time to focus on the processes of team functioning; however, some were uncomfortable with a focus on teamwork at the expense of delivering direct patient care. The IMT is a relatively low-cost, structured, reflective way to enhance team function. It empowers individuals to understand and value their own, and others' roles and responsibilities within the team; identify barriers to effective teamwork, and develop and implement appropriate solutions to these. To be successful, teams need protected time to take for reflection, and executive support to be able to broker changes that are beyond the scope of the team. [ABSTRACT FROM AUTHOR]

Background. Maternal obesity and excessive gestational weight gain (GWG) are on the rise with negative impact on pregnancy and birth outcomes. Research into managing GWG using accessible technology is limited. The maternal obesity management using mobile technology (MOMTech) study aimed at evaluating the feasibility of text messaging based complex intervention designed to support obese women (BMI ≥ 30) with healthier lifestyles and limit GWG. Methods. Participants received two daily text messages, supported by four appointments with healthy lifestyle midwife, diet and activity goal setting, and self-monitoring diaries. The comparison group were obese mothers who declined to participate but consented for their routinely collected data to be used for comparison. Postnatal interviews and focus groups with participants and the comparison group explored the intervention’s acceptability and suggested improvements. Results. Fourteen women completed the study which did not allow statistical analyses. However, participants had lower mean GWG than the comparison group (6.65 kg versus 9.74 kg) and few (28% versus 50%) exceeded the Institute of Medicine’s upper limit of 9 kg GWG for obese women. Conclusions. MOMTech was feasible within clinical setting and acceptable intervention to support women to limit GWG. Before further trials, slight modifications are planned to recruitment, text messages, and the logistics of consultation visits. [ABSTRACT FROM AUTHOR]

Objective Multidisciplinary team (MDT) meetings are assumed to produce better decisions and are extensively used to manage chronic disease in the National Health Service (NHS). However, evidence for their effectiveness is mixed. Our objective was to investigate determinants of MDT effectiveness by examining factors influencing the implementation of MDT treatment plans. This is a proxy measure of effectiveness, because it lies on the pathway to improvements in health, and reflects team decision making which has taken account of clinical and non-clinical information. Additionally, this measure can be compared across MDTs for different conditions. Methods We undertook a prospective mixed-methods study of 12 MDTs in London and North Thames. Data were collected by observation of 370 MDT meetings, interviews with 53 MDT members, and from 2654 patient medical records. We examined the influence of patient-related factors (disease, age, sex, deprivation, whether their preferences and other clinical/ health behaviours were mentioned) and MDT features (as measured using the 'Team Climate Inventory' and skill mix) on the implementation of MDT treatment plans. Results The adjusted odds (or likelihood) of implementation was reduced by 25% for each additional professional group represented at the MDT meeting. Implementation was more likely in MDTs with clear goals and processes and a good 'Team Climate'(adjusted OR 1.96; 95% CI 1.15 to 3.31 for a unit increase in Team Climate Inventory (TCI) score). Implementation varied by disease category, with the lowest adjusted odds of implementation in mental health teams. Implementation was also lower for patients living in more deprived areas (adjusted odds of implementation for patients in the most compared with least deprived areas was 0.60, 95% CI 0.39 to 0.91). Conclusions Greater multidisciplinarity is not necessarily associated with more effective decision making. Explicit goals and procedures are also crucial. Decision implementation should be routinely monitored to ensure the equitable provision of care. [ABSTRACT FROM AUTHOR]

Background Assessments of personality disorder (PD) by clinicians or researchers are not always congruent with the problems that clients view as most salient. This can result in disagreement over areas for change, leading to dissatisfaction and the risk of treatment attrition. Method The sample comprised 141 treatment-seeking adults with PD. Each described the five things they most wanted to change about themselves. These target problems were compared with PD diagnoses obtained from the International Personality Disorder Examination. Results The congruence between the clients' target problems and PD traits identified by the professionals was generally weak. Disagreement arose where a client's target problem was not a PD trait and, less frequently, where the client and the professional agreed on the presence of a trait but not on its importance. Surprisingly, doubting the trustworthiness of others was the most commonly reported target problem in this treatment-seeking sample even though many such participants did not qualify for that particular paranoid trait. Conclusion Personality disorder diagnoses were generally poor indicators of the problems these clients cited as most important. This lack of correspondence may explain some of the lack of effectiveness of interventions for PD. Copyright © 2012 John Wiley & Sons, Ltd. Key Practitioner Message: The problem that a client with personality disorder (PD) views as most important may only be weakly identified in a formal diagnostic assessment., Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PD traits are insufficient to describe fully the things clients most want to change about themselves., Many clients with PD consider difficulty trusting others to be their most important problem, despite not qualifying for that particular paranoid trait., Risk of disagreement between the clinician and the client might be reduced if both parties can engage in a discussion about the results of any formal diagnostic assessment. [ABSTRACT FROM AUTHOR]

Aims: To explore the use of computer-assisted therapy (CAT) by homeless drug users (HDUs) living in hostels in order to assess the likely acceptability of online treatment for this population. Methods: Repeat semi-structured interviews with 30 HDUs (25 men; 5 women) who agreed to participate in a 12-week mentor-assisted online drug treatment programme: Breaking Free Online (BFO). Interviews were transcribed, coded and analysed using Framework. Findings: Prior to the first BFO session, HDUs' hopes and goals were seldom confined to reducing their drug consumption. Most described broader recovery and wellbeing aims, and many wanted BFO to improve their computing skills. Nearly all participants expressed positive feelings about the programme after both their first and last session, with clients highlighting BFO's accessibility, flexibility, interactive capabilities and user-friendly interface. Negative comments related to structural barriers that prevented the programme from being used as intended. After the last BFO session, only four clients reported reduced substance use, but other personal, psychological, educational and social benefits were identified. Conclusions: There is potential for using CAT programmes, such as BFO, with HDUs living in hostels. However, evaluations might need to assess a range of recovery indicators in order to gauge any evidence of treatment success. [ABSTRACT FROM AUTHOR]

Background Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS). Methods Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a highlevel summary. Results We found an almost universal desire to provide the best quality of care. We identified many 'bright spots' of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of the paper is to report the findings from research into the governance of adult protection in Scotland, with particular focus on the outcomes of provision for multi-agency leadership and management of adult safeguarding in the Adult Support and Protection (Scotland) Act 2007. Comparisons will be drawn between these findings and the evidence on the governance of adult safeguarding in England. Design/methodology/approach – The study comprised a thematic analysis of Adult Protection Committee (APC) biennial reports on implementation of the 2007 Act to the Scottish Government, associated documentation, and key informant interviews with professionals involved in adult protection leadership and practice. Findings – A rich and complex pattern of arrangements, activities, experiences and challenges were identified across a number of dimensions, including management structures of APCs, development of policies and procedures, multi-agency working, training, performance assessment and quality management, engagement of service users and carers and operation of the 2007 Act. Research limitations/implications – Service users and carers were not directly involved in the documentary review or key informant interviews. There remains a need to investigate the impacts on practice and service user experience of different forms of governance of adult protection arrangements. Practical implications – The paper identifies outcomes and challenges in respect of multi-agency approaches to governance taken by APCs in Scotland. Originality/value – The paper offers the first formal evaluation of governance of adult protection systems in Scotland and includes comparative analysis with research findings on the governance of adult safeguarding in England. [ABSTRACT FROM AUTHOR]

Objectives: It is increasingly recognized that the design characteristics of pay-for-performance schemes are importantin determining their impact. One important but under-studied design aspect is the extent to which pay-for-performanceschemes reflect local priorities. The English Department of Health White Paper High Quality Care for All introduced aCommissioning for Quality and Innovation (CQUIN) Framework from April 2009, under which local commissioners andproviders were required to negotiate and implement an annual pay-for-performance scheme. In 2010/2011, theseschemes covered 1.5% (£1.0bn) of NHS expenditure. Local design was intended to offer flexibility to local prioritiesand generate local enthusiasm, while retaining good design properties of focusing on outcomes and processes witha clear link to quality, using established indicators where possible, and covering three key domains of quality (safety;effectiveness; patient experience) and innovation. We assess the extent to which local design achieved these objectives.Methods: Quantitative analysis of 337 locally negotiated CQUIN schemes in 2010/2011, along with qualitative analysisof 373 meetings (comprising 800 hours of observation) and 230 formal interviews (audio-recorded and transcribedverbatim) with NHS staff in 12 case study sites.Results: The local development process was successful in identifying variation in local needs and priorities for qualityimprovement but the involvement of frontline clinical staff was insufficient to generate local enthusiasm around theschemes. The schemes did not in general live up to the requirements set by the Department of Health to ensure thatlocal schemes addressed the original objectives for the CQUIN framework.Conclusions: While there is clearly an important case for local strategic and clinical input into the design of pay-forperformanceschemes, this should be kept separate from the technical design process, which involves defining indicators,agreeing thresholds, and setting prices. These tasks require expertise that is unlikely to exist in each locality. The CQUINframework potentially offered an opportunity to learn how technical design influenced outcome but due to the highdegree of local experimentation and little systematic collection of key variables, it is difficult to derive lessons from thisunstructured experiment about the impact and importance of different technical design factors on the effectiveness ofpay-for-performance. Balancing the policy goal of localism with the objective of improving patient outcomes leads us toconclude that a somewhat firmer national framework would be preferable to a fully locally designed framework. [ABSTRACT FROM AUTHOR]

BACKGROUND: Early rehabilitation has been identified as key to improving physical function and aiding in long-term recovery in critically ill patients. Surveys of physiotherapy practice have highlighted variations and issues with the provision of rehabilitation services in this patient population. However, there have been no qualitative studies exploring physiotherapist's views of implementing early rehabilitation in critically ill patients. AIM: To explore physiotherapist's understanding and experiences of early rehabilitation in critically ill patients. METHODS: A qualitative exploratory design using semi-structured interviews with six physiotherapists from one NHS hospital trust. RESULTS: Thematic content analysis identified how participants conceptualised early rehabilitation in two broad themes of adherence and collaborative working. CONCLUSIONS: Physiotherapists identified that adherence is an issue in clinical practice and collaborative working is integral to patient care. Awareness of the barriers to adherence and collaborative working and strategies that can be used to overcome them is central to improving rehabilitation in critically ill patients. [ABSTRACT FROM AUTHOR]

AimTo explore whether and how health visitors experience ethical tensions between the public health agenda and the need to be responsive to individual clients.BackgroundCurrent health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This may generate tensions.MethodsA total of 17 semi-structured individual interviews covering participants’ experiences of implementing public health interventions and perceptions of the ethical tensions involved were conducted. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach.FindingsHealth visitors raised a number of ethical concerns, which they attributed to organisational resource allocation and the introduction of protocols and targets relating to public health goals. They did not always regard it as appropriate to raise topics that employing organisations had identified as public health priorities with particular clients for whom they were not priorities, or who had other more pressing needs. They noted that resources that were allocated towards reaching public health targets were unavailable for clients who needed support in other areas. Organisational protocols designed to monitor performance put pressure on health visitors to prioritise achieving targets and undermined their ability to exercise professional judgement when supporting individual clients. This had implications for health visitors’ sense of professionalism. Health visitors saw trusting relationships as key to effective health visiting practice, but the requirement to implement public health priorities, combined with a lack of resources in health visiting, eroded their ability to form these. Policies need to be evaluated with regard to their impact upon a broader range of processes and outcomes than public health goals. The erosion of health visitors’ professional values and ability to develop relationships with clients could have numerous adverse implications. [ABSTRACT FROM PUBLISHER]

Objectives: This study provided an in-depth examination of the implicit ability beliefs held by elite British track and field athletes, including the antecedents and consequences of these beliefs. Design and Methods: A qualitative design was employed involving semi-structured interviews with 4 Olympic hopefuls in the sport of track and field athletics. Thematic analysis was utilised to interpret the results of the study, involving a combination of inductive and deductive approaches. Results: The core components of ability beliefs included beliefs that ability is stable, ability is malleable, and that it is possible to build on natural ability. A variety of personal, social and environmental antecedents appeared to influence the athletes'' ability beliefs. The consequences of implicit beliefs encompassed three major themes, which were achievement motivation, setbacks and attributions for success and failure. Conclusions: The results from the analysis indicated that the athletes'' implicit beliefs were very specific, as their beliefs about ability appeared to underpin sport-specific performance. The belief that ability was malleable was universal amongst the athletes and this may be related to their age, experience, high perceived ability and the high level at which they compete. However, the athletes believed that although natural ability is useful, talent is only a small part of the equation as learning, improving and working hard are all necessary for success at the highest level. [Copyright &y& Elsevier]

Purpose – This article aims to consider the transfer of public health responsibilities to Local Authorities, and implications for promotion of health and wellbeing through partnership. The article describes findings of interviews with stakeholders in one London borough. Design/methodology/approach – Elements of the Partnership Assessment Tool (PAT) provided a framework for semi-structured interviews. Findings – A limited history of successful partnership between health and social care was attributed to a focus on partnership structures over behaviours. Transfer of public health responsibilities to the Local Authority was seen as an opportunity to address the wider determinants of health, but a shared vision for health and wellbeing had not been articulated. There appeared to be an expectation that the public health team would operate in a network partnership model. Research limitations/implications – While the PAT is presented as a complete tool, this project isolated elements of the tool to support development of the interview structure. The project did not include interviews with clinical members of the developing Clinical Commissioning Group, who may have different requirements of the public health function; this is an area for future research. Practical implications – Recommendations are made to support effective integration of public health responsibilities into Local Authority functions. Originality/value – This project provides a snapshot of preparations for the transfer of public health responsibilities to the Local Authority in one area. Relevant literature suggests that experiences in this area are not unique and findings and recommendations are likely to be applicable elsewhere. [ABSTRACT FROM AUTHOR]

Purpose/Objectives: To describe the needs of testicular cancer survivors, develop a nurse-led workshop, and explore the experience of participation.Research Approach: A systematic intervention development process was used to design a self-management workshop for cancer survivors, which then was evaluated qualitatively.Setting: Outpatient clinic in England.Participants: 26 healthcare professionals, charity workers, family members, and testicular cancer survivors participated in the intervention development process. Six testicular cancer survivors attended the workshop and participated in the postintervention focus group discussion.Methodologic Approach: Ten participants, including four survivors, completed the initial needs assessment interviews. Twenty-six participants then rated the identified needs on two dimensions: importance to self-management and changeability via a self-management intervention. Literature review and expert consultation were used to identify potential workshop components. To explore the experience of attending the intervention, six testicular cancer survivors who participated in the nurse-led workshop were interviewed six weeks later.Findings: The workshop was well received by participants, who appreciated the goal-setting and information provision activities. The men also felt that they had benefited from the experience of being in the group.Conclusions: Testicular cancer survivors had unmet post-treatment needs. The systematic intervention development method led to an evidence-based workshop to address those needs. Men reported benefits from attending the workshop, which may help maintain and improve health.Interpretation: Nurse-led workshops can address the current unmet needs of testicular cancer survivors.Knowledge Translation: Testicular cancer survivors may require support with health information, maintaining psychological health, and monitoring cancer symptoms. Survivors also need help planning and maintaining an active lifestyle. In addition, a brief workshop approach to intervention delivery is acceptable to testicular cancer survivors. [ABSTRACT FROM AUTHOR]

Based on the developmental theory presented by Gagné (2009), we examined the factors perceived to influence the development of elite youth football players at a critical stage in their progression to the professional level. Transcribed interviews with ten expert development coaches were inductively and deductively content analysed. Conceptualisation of the data revealed six interrelated higher-order categories that represented the factors perceived to either positively or negatively influence player development. These were: awareness (e.g. self-awareness, awareness of others); resilience (e.g. coping with setbacks, optimistic attitude); goal-directed attributes (e.g. passion, professional attitude); intelligence (e.g. sport intelligence, emotional competence); sport-specific attributes (e.g. coachability, competitiveness); and environmental factors (e.g. significant others, culture of game). In this investigation, awareness emerged as a fundamental and mediating element for understanding how young players are able to transition to the professional level. Collectively, the findings underline the multidimensional nature of talent development and suggest that an intricate combination of stage-specific factors must manifest for gifted young players to translate their potential into excellence. Mechanisms by which academies could be helped to shape the characteristics and conditions associated with effective development are discussed. [ABSTRACT FROM AUTHOR]

ABSTRACT From the findings of a study examining the perspective of parents using Intensive Family Support Service based in northern England, this paper examines the constituent elements required for effective relationship-based practice. Although the study is based in a single site in England, the findings are more broadly relevant, given both national and international interests in relationship-based practice in child protection. The participants in this study - parents whose children had been assessed as being 'at the edge of care'- were asked to comment on the intervention they had received. Analysis of parents' interviews suggests that the service user-worker relationship was critical to their positive experience of the service. The paper provides an analysis of parents' descriptions of 'positive relationships' and identifies the key themes. It then considers these findings in the context of contemporary children and families' social work practice. Engaging with current debates, the paper makes reference to the impact of modernization, which has served to erode effective face-to-face work with families, given excessive 'backroom' demands of administration and audit. Discussion engages with an emerging emphasis on effective relationship-based practice following reports from Munro and the Social Work Reform Board. In this context, the paper concludes that the views of these families whose children are on the 'edge of care' offers insights into the skills required for relationship-based practice. [ABSTRACT FROM AUTHOR]

Background: Despite recognition of the need for increased long-term support for people with aphasia following stroke, there remains limited evidence for effective service-level interventions. Aims: To evaluate the outcomes and experiences of people participating in the Communication Hub for Aphasia in North Tyneside (CHANT), a 2-year partnership project between health, local authority and third-sector services, shaped by people with aphasia, which provided a coordinated programme of support and interventions for people with long-term aphasia following stroke. Methods & Procedures: Quantitative and qualitative methods were used in the evaluation. Thirty-nine participants with aphasia were recruited to the 12-month study as they became part of CHANT, with 20 completing all measures at the end of the study. Participants had no other speech and language therapy during the study. Quantitative measures (before and after intervention) were used for quality of life, self-report outcomes and goal attainment. Three of the participants with aphasia and three further people involved in the service (carer, volunteer, public sector worker) each agreed to a series of five semi-structured interviews over a 9-month period. A total of 28 interviews were collected using neutral interviewers; these were transcribed and analysed by a team within NVivo8 software, based on interpretive principles from grounded theory. Thematic analysis of the narratives explored the experience of engaging with CHANT, and the barriers and facilitators affecting quality of life. Outcomes & Results: People with aphasia made significant gains in quality of life (in particular, in communication and psychosocial adjustment to stroke) and self-report measures of change. A total of 82% of real-life goals set as part of intervention were fully or partially achieved at follow-up. Five core themes emerged from the narratives: 'Quality of life', 'Barriers', 'Facilitators', 'Types of CHANT activity' and 'Effectiveness'. The intervention was evaluated through the theme of 'Effectiveness' in relation to the other themes, encapsulating emerging participant views (including the type and timeliness of activity, expectations of outcomes, resources and perceived value). The impact of the intervention was also analysed in terms of identifying barriers and providing facilitators. Conclusions & Implications: The quantitative and qualitative (narrative) findings were complementary in demonstrating the effectiveness of the CHANT service delivery model. Moreover, the narratives, through a longitudinal perspective, provided evidence about people's experience of intervention for long-term aphasia. The findings provide foundations for further work into long-term recovery, intervention and adjustment to aphasia post-stroke. [ABSTRACT FROM AUTHOR]

Satisfaction with service-related choices has not received much research attention, especially beyond medical/health-related decisions. This paper reports findings from an analysis of parents' accounts of making service-related choices with, or on behalf of, a disabled son or daughter with a degenerative condition. It focuses particularly on factors and processes, which contribute to parents' satisfaction. This is particularly interesting given that sub-optimal outcomes or negative consequences are often experienced following a service-related choice being implemented. The data reported here were collected as part of a larger, longitudinal study (the Choice and Change project) of service users' experiences of choice-making, including the outcomes and consequences of those choices. Parents of disabled young people with degenerative conditions formed part of this sample. The accounts of 14 of these parents, collected over three interviews during a two and a half-year period, all of whom expressed satisfaction with the medium- to long-term outcomes of a service-related choice, were selected for specific analyses to understand what underlies satisfaction with service-related choices. Clarity of the desired outcome for the young person supported effective decision-making and led parents to feel confident that the best possible choice was being made. Evidence of desired outcomes being attained were used by parents to 'trade off' the negative consequences of a choice. These included the considerable demands placed on parents' personal, financial and practical resources to operationalise a choice, and the emotional impact incurred by significant changes such as the loss of the carer role. The passage of time was important in allowing evidence of positive outcomes to emerge, psychological or emotional adjustments to be made, and for parents to develop trust in new service providers. The findings suggest that practitioners can have an important role in both practical and emotional support for parents' choice-making for, or with, their disabled son/daughter. [ABSTRACT FROM AUTHOR]

Objectives: To explore some of the key assumptions underpinning the continued development of general practitioner-led commissioning in health services. Methods:Qualitative data from two studies of service improvement in the English NHS were considered against England's plans for GP-led commissioning. These data were collected through in-depth interviews with a total of 187 professionals and 99 people affected by services in 10 different primary care trust areas across England between 2008 and 2009. Results: Internationally, GPs are seen to have a central position in health systems. In keeping with this, the English policy places emphasis on the 'pivotal role' of general practitioners, considered to be ideally placed to commission in the best interests of their patients. However, our evidence suggests that general practitioners do not always have a pivotal role for all patients. Moreover, it is planned that the new commissioning groups in England will not be subject to top-down performance management and this raises the question of how agreed quality standards will be met under the proposed new system. Conclusions: This paper questions the assumption that GPs are best placed to commission health services in a way that meets quality standards and leads to equitable outcomes. There is little evidence to suggest that GPs will succeed where others have failed and a risk that, without top-down performance management, service improvement will be patchy, leading to greater, not reduced, inequity. [ABSTRACT FROM AUTHOR]

Objective: To investigate the external and internal governance of NHS foundation trusts (FTs), which have increased autonomy, and local members and governors unlike other NHS trusts. Methods: In depth, three-year case studies of four FTs; and analysis of national quantitative data on all FT hospitals and NHS Trust hospitals to give national context. Data included 111 interviews with managers, clinicians, governors and members, and local purchasers; observation of meetings; and analysis of FTs' documents. Results: The four case study FTs were similar to other FTs. They had used their increased autonomy to develop more business-like practices. The FT regulator, Monitor, intervened only when there were reported problems in FT performance. National targets applying to the NHS also had a large effect on FT behaviour. FTs saw themselves as part of the local health economy and tried to maintain good relationships with local organisations. Relationships between governors and the FTs' executives were still developing, and not all governors felt able to hold their FT to account. The skills and experience of staff members and governors were under-used in the new governance structures. Conclusions: It is easier to increase autonomy for public hospitals than to increase local accountability. Hospital managers are likely to be interested in making decisions with less central government control, whilst mechanisms for local accountability are notoriously difficult to design and operate. Further consideration of internal governance of FTs is needed. In a deteriorating financial climate, FTs should be better placed to make savings, due to their more business-like practices. [ABSTRACT FROM AUTHOR]

Objectives: To examine whether the Health System Reforms delivered the promise of being a coherent and mutually supporting reform programme; to identify the underlying programme theory of the reform programme; to reflect on whether lessons have been learned. Methods: Documentary analysis mapping the implicit and explicit programme theories about how the reforms intended to achieve its goals and outcomes. Semi-structured interviews with policy-makers to further understand the programme theory. Results: The Health System Reforms assumed a 'one size fits all' approach to policy implementation with little recognition that some contexts can be more receptive than others. There was evidence of some policy evolution and rebalancing between the reform streams as policy-makers became aware of some perverse incentives and unforeseen consequences. Later elements aimed to restore balance to the system. Conclusions: The Health System Reforms do not appear to comprise a coherent and mutually supportive set of levers and incentives. They appear unbalanced with the centre of gravity favouring suppliers over commissioners. However, recent reform changes have sought to redress this imbalance to some extent, suggesting that lessons have been learned and policies have been adapted over time. [ABSTRACT FROM AUTHOR]

Objectives: To describe the current use of external support by commissioners in the English NHS; assess what impact it is having; explore the factors influencing effectiveness; and draw out the implications for the future of NHS commissioning. Methods: (1) Two national surveys of primary care trust managers. (2) Qualitative interviews and focus groups with representatives of 12 firms providing support services to commissioners. (3) Focus groups in three primary care trusts and interviews with representatives of two strategic health authorities (SHAs). Results: The majority of survey respondents reported using external support (89% in 2010). Satisfaction levels were reasonably high, with most rating the service received as excellent or good. Perceived impact in the case study sites was mixed, but benefits were reported in a number of areas. There were cases where external support had not achieved its goals. Several factors contributed to success or failure, including difficulties around procuring external support; building effective working relationships; and implementing the ideas generated by external partners. There was evidence that commissioners do not always use support in a way that takes full advantage of the skills existing in external organizations. There was also some evidence that poorer performing organizations may be less successful in using external support effectively. Conclusions: External support can play a role in improving the quality of commissioning. However, certain pitfalls must be avoided if it is to be used effectively. The role of external support will evolve (and may expand) as commissioning responsibilities are transferred to general practice consortia. [ABSTRACT FROM AUTHOR]

Objectives: Root cause analysis (RCA) is a framework for structured investigations of safety incidents. Our aim was to identify the barriers to successful learning in health care and to make recommendations for service development. Methods: A qualitative study that 'tracked' the investigation procedures and practices of ten patient safety incidents in two National Health Service (NHS) hospitals. Non-participant observations of the complete investigation process in various managerial and administrative settings, together with semi-structured qualitative interviews with those involved in the process, and following the completion of the final report. Results: There are several challenges to undertaking root cause analysis in health care. These are associated with forming and leading the investigation team; gathering and analysing supporting evidence; and formulating and implementing service improvements. Undertaking root cause analysis remains a complex non-linear task which entails balancing a multiplicity of concerns and expectations. Supporting enhanced incident investigation requires keeping in focus the instrumental aim of triggering sustainable service improvement and not for the investigation to become an end in itself. Conclusions: Health services leaders need to provide open endorsement of root cause analysis and of the staff carrying it out; enhance staff participation within learning activities and new analytic tools; and develop capabilities in change management. [ABSTRACT FROM AUTHOR]

In 2000, Skills for Life, a new strategy for literacy, numeracy and language education was introduced in England. It included new core curricula, tough new targets for learner achievement, and significantly increased accountability requirements for teachers and colleges. Many teachers found aspects of this new system difficult. This paper analyses interviews carried out with teachers in 2002 to identify the reasons underlying their resistance. In the interviews, teachers consistently drew on a well-defined discourse which defined 'good' teaching as teaching that is responsive to the learner, negotiating teaching in response to learners' goals and characteristics, and flexible in the teaching moment. Resistance arose when aspects of the centralised strategy were perceived to constrain teachers' ability to respond to learners in this way, being driven more by external demands and advance planning than by responsiveness to learners. Teachers attempted to develop strategies to maintain responsiveness while working within the new strategy. [ABSTRACT FROM AUTHOR]

This paper discusses the role of trust and shared goals in relation to participation in inter-organisational and multi-agency partnerships. It draws on a study of partnership working in England and focuses in particular on the perspectives of senior managers of post-16 education and training providers with substantial experience of working in local and regional partnerships. The research explored the concept and practice of partnership through a qualitative case study of a sub-regional partnership and the main methods used for data collection were observations of partnership meetings, documentary evidence of partnership working and semi-structured interviews with members of the partnership. The findings presented in this paper emanate principally from the interview data and reveal the importance and differentiated nature of trust in partnership working and the place of both trust and shared goals in effective and sustained partnerships. [ABSTRACT FROM AUTHOR]