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The purpose of this study was to explore relationships between senior management team culture and organizational performance in English hospital organizations (NHS trusts [National Health Service]). We used an established culture-rating instrument, the Competing Values Framework, to assess senior management team culture. Organizational performance was assessed using a wide variety of routinely collected measures. Data were gathered from all English NHS acute hospital trusts, a total of 197 organizations. Multivariate econometric analyses were used to explore the associations between measures of culture and measures of performance using regressions, ANOVA, multinomial logit, and ordered probit. Organizational culture varied across hospital organizations, and at least some of this variation was associated in consistent and predictable ways with a variety of organizational characteristics and measures of performance. The findings provide particular support for a contingent relationship between culture and performance. [ABSTRACT FROM AUTHOR]

Abstract In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson's concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues’ perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of ‘soft coercion’. [ABSTRACT FROM AUTHOR]

A comparative study of 167 pregnant teenagers in Devon attending either antenatal booking clinics or for National Health Service (NHS) termination of pregnancy was carried out to determine differences in their characteristics, use and experience of local family planning services. Teenagers presenting for termination of pregnancy were younger and more likely to say that they had wished to avoid getting pregnant. Whether the teenager was in a stable relationship was strongly associated with the outcome of the pregnancy, with single girls being more likely to choose a termination of pregnancy. The termination of pregnancy group were also more likely to be condom users, and to have learned about their method of contraception from school rather than from health care professionals. Teenagers' frequency of contact with family planning services suggested that teenagers choosing a termination were less likely than antenatal attenders to have attended regularly. This was mainly due to differences in behaviour among teenagers attending their general practitioner (GP) for contraceptive advice: teenagers having a termination were more likely to describe their visit to their GP as embarrassing. These findings have implications for local family planning services attempting to reduce the number of unwanted teenage pregnancies. [ABSTRACT FROM AUTHOR]

In an attempt to support care integration that promotes joined up service provision and patient-centred care across care boundaries, local health and social care organisations have embarked on several initiatives and approaches. A key component of service integration is the co-location of different professional groups. In this study, we consider the extent to which co-location is an enabler for service integration by examining multi-professional community care teams. The study presents findings from a qualitative evaluation of integrated care initiatives in a borough of East London, England, undertaken between 2017 and 2018. The evaluation employed a participatory approach, the Researcher-in-Residence model. Participant observation (n = 80 hr) and both semi-structured individual (n = 16) and group interviews (six groups, n = 17 participants) were carried out. Thematic analysis of the data was undertaken. The findings show that co-location can be an effective enabler for service integration providing a basis for joint working, fostering improved communication and information sharing if conditions such as shared information systems and professional cultures (shared beliefs and values) are met. Organisations must consider the potential barriers to service integration such as differing professional identity, limited understanding of roles and responsibilities and a lack of continuity in personnel. Co-location remains an important facet in the development of multi-professional teams and local service integration arrangements, but as yet, has not been widely acknowledged as a priority in care practice. Organisations that are committed to greying care boundaries and providing joined up patient care must ensure that sufficient focus is provided at the service delivery level and not assume that decades of silo working in health and social care and strong professional cultures will be resolved by co-location., (© 2020 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.)

Integrated care has been proposed as an organising principle to address the challenges of the rising demand for care services and limited resources. There is limited understanding of the role of learning in integrated care systems. Organisational Learning (OL) theory in the guise of 'Learning Practice' can offer a lens to study service integration and reflect on some of the challenges faced by multi-professional teams in developing a learning culture. The study presents findings from two qualitative evaluations of integrated care initiatives in three East London boroughs, England, undertaken between 2017 and 2018. The evaluations employed a participatory approach, the researcher-in-residence model, to coproduce findings with frontline staff working in multi-professional teams in community care. Thematic analysis was undertaken using an adapted version of the 'Learning Practice' framework. The majority of learning in the teams was single loop i.e. learning was mainly reactive to issues that arise. Developing a learning culture in the three boroughs was hindered by the differences in the professional and organisational cultures of health and social care and challenges in developing effective structures for learning. Individual organisational priorities and pressures inhibited both the embedding of learning and effective integration of care services at the frontline. Currently, learning is not inherent in integrated care planning. The adoption of the principles of OL optimising learning opportunities, support of innovation, managed risk taking and capitalising on the will of staff to work in multidisciplinary teams might positively contribute to the development of service integration., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: The purpose of this paper is to present the findings arising from a three year research project which investigated a major system-wide change in the design of the NHS in England. The radical policy change was enshrined in statute in 2012 and it dismantled existing health authorities in favour of new local commissioning groups built around GP Practices. The idea was that local clinical leaders would "step-up" to the challenge and opportunity to transform health services through exercising local leadership. This was the most radical change in the NHS since its inception in 1948., Design/methodology/approach: The research methods included two national postal surveys to all members of the boards of the local groups supplemented with 15 scoping case studies followed by six in-depth case studies. These case studies focused on close examination of instances where significant changes to service design had been attempted., Findings: The authors found that many local groups struggled to bring about any significant changes in the design of care systems. But the authors also found interesting examples of situations where pioneering clinical leaders were able to collaborate in order to design and deliver new models of care bridging both primary and secondary settings. The potential to use competition and market forces by fully utilising the new commissioning powers was more rarely pursued., Practical Implications: The findings carry practical implications stemming from positive lessons about securing change even under difficult circumstances., Originality/value: The paper offers novel insights into the processes required to introduce new systems of care in contexts where existing institutions tend to revert to the status quo. The national survey allows accurate assessment of the generalisability of the findings about the nature and scale of change.

Objective: A growing proportion of older people live in care homes and are at high risk of preventable harm. This study describes a participatory qualitative evaluation of a complex safety improvement intervention, comprising training, performance measurement and culture-change elements, on the safety of care provided for residents., Design: A participatory qualitative study., Setting: Ninety care homes in one geographical locality in southern England., Participants: A purposeful sample of care home managers, front-line staff, residents, quality improvement facilitators and trainers, local government and health service commissioners, and an embedded researcher., Main Outcome Measures: Changes in care home culture and work processes, assessed using documentary analysis, interviews, observations and surveys and analysed using a framework-based thematic approach., Results: Participation in the programme appears to have led to changes in the value that staff place on resident safety and to changes in their working practices, in particular in relation to their desire to proactively manage resident risk and their willingness to use data to examine established practice. The results suggest that there is a high level of commitment among care home staff to address the problem of preventable harm. Mobilisation of this commitment appears to benefit from external facilitation and the introduction of new methods and tools., Conclusions: An evidence-based approach to reducing preventable harm in care homes, comprising an intervention with both technical and social components, can lead to changes in staff priorities and practices which have the potential to improve outcomes for people who live in care homes.

Aim: Early intervention services (EIS) for psychosis are being implemented, internationally. It is important to learn from established examples and define the components and intensity of services that provide good value for money. This study aims to assess the cost-effectiveness of EIS according to how closely they adhered to the recommendations of the English Department of Health 2001 Policy Implementation Guide (PIG)., Methods: EIS from the National Eden Study were assessed using a measure of fidelity to the PIG that rated the presence or absence of 64 recommended items relating to team structure and practice. EIS were then classified into three groups: those with fidelity of 75-80%, 81-90% and 91-95%. Patient-level resource use and outcomes were measured 1 year following inception into the service; costs were calculated and combined with quality-adjusted life years (QALYs) gained., Results: At a threshold of £20 000 per QALY, the 81-90% fidelity group had a 56.3% likelihood of being the most cost-effective option followed by 75-80% fidelity at 35.8% and 91-95% fidelity group (7.9%)., Conclusions: The results from England suggest that striving to maximize fidelity may not be warranted, but that dropping below a certain level of fidelity may result in inefficient use of resources., (© 2017 John Wiley & Sons Australia, Ltd.)

Background: Clinical commissioning groups (CCGs) were established in England in 2013 to encourage GPs to exert greater influence over the processes of service improvement and redesign in the NHS. Little is known about the extent and the ways in which GPs have assumed these leadership roles., Aim: To explore the nature of clinical leadership of GPs in CCGs, and to examine the enablers and barriers to implementing a policy of clinical leadership in the NHS., Design and Setting: A qualitative multi-case study approach in six localities across England. The case studies were purposefully sampled to represent different geographical localities and population demographics, and for their commitment to redesigning specified clinical or service areas., Method: Data were collected from the case study CCGs and their partner organisations using a review of relevant documents, semi-structured individual or group interviews, and observations of key meetings. The data were analysed thematically and informed by relevant theories., Results: GPs prefer a collaborative style of leadership that may be unlikely to produce rapid or radical change. Leadership activities are required at all levels in the system from strategy to frontline delivery, and the leadership behaviours of GPs who are not titular leaders are as important as formal leadership roles. A new alliance is emerging between clinicians and managers that draws on their different skillsets and creates new common interests. The uncertain policy environment in the English NHS is impacting on the willingness and the focus of GP leaders., Conclusion: GPs are making an important contribution as leaders of health service improvement and redesign but there are significant professional and political barriers to them optimising a leadership role., (© British Journal of General Practice 2018.)

Objectives: This study explores the barriers and facilitators that impact on the motivation of practitioners to participate in a quality improvement collaborative., Design: A qualitative and formative evaluation using a participatory approach, the researcher-in-residence model which embraces the concept of 'coproducing' knowledge between researchers and practitioners using a range of research methods such as participant observation, interviews and documentary analysis. The design, creation and application of newly generated evidence are facilitated by the researcher through negotiation and compromise with team members., Participants: Senior and middle managers, doctors and nurses., Setting: Two hospitals in Southeast England participating in a Patient Safety Improvement Collaborative and the facilitator (host) of the collaborative, based in Central London., Results: The evaluation has revealed facilitators and barriers to motivation categorised under two main themes: (1) inherent motivation and (2) factors that influence motivation, interorganisational and intraorganisational features as well as external factors. Facilitators included collaborative 'champions,' individuals who drove the quality improvement agenda at a local level, raising awareness and inspiring colleagues. The collaborative itself acted as a facilitator, promoting shared learning as well as building motivation for participation. A key barrier was the lack of board engagement in the participating National Health Service organisations which may have affected motivation among front-line staff., Conclusions: Collaboratives maybe an important way of engaging practitioners in quality improvement initiatives. This study highlights that despite a challenging healthcare environment in the UK, there remains motivation among individuals to participate in quality improvement programmes as they recognise that improvement approaches may facilitate positive change in local clinical processes and systems. Collaboratives can harness this individual motivation to facilitate spread and adoption of improvement methodology and build engagement across their membership., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Competing Interests: Competing interests: None declared.

Background: Early intervention services (EIS) comprise low-stigma, youth-friendly mental health teams for young people undergoing first-episode psychosis (FEP). Engaging with the family of the young person is central to EIS policy and practice.AimsBy analysing carers' accounts of their daily lives and affective challenges during a relative's FEP against the background of wider research into EIS, this paper explores relationships between carers' experiences and EIS., Method: Semi-structured longitudinal interviews with 80 carers of young people with FEP treated through English EIS., Results: Our data suggest that EIS successfully aid carers to support their relatives, particularly through the provision of knowledge about psychosis and medications. However, paradoxical ramifications of these user-focused engagements also emerge; they risk leaving carers' emotions unacknowledged and compounding an existing lack of help-seeking., Conclusions: By focusing on EIS's engagements with carers, this paper draws attention to an urgent broader question: as a continuing emphasis on care outside the clinic space places family members at the heart of the care of those with severe mental illness, we ask: who can, and should, support carers, and in what ways?, (© The Royal College of Psychiatrists 2015.)

Objective: This study aimed to determine if the inception of Early Intervention Services (EISs) is followed by an improvement in the prompt treatment of people with first episode psychosis., Method: A prospective cohort study of referrals to new and established EISs was conducted at 1, 2, 3, and 4 years after inception of new EIS. The study was conducted with 14 (seven new and seven established) secondary care EIS within geographically defined catchment areas in England between 2005 and 2009. Participants included 1027 consecutive referrals to EIS aged 14-35 with a first episode of psychosis. Duration of untreated psychosis (DUP) and number of participants treated adequately within 6 months of onset were the main outcome measures., Results: A significant downward trend across yearly cohorts for DUP for new EIS (F1,549=8.4, p=0.004) but not for established EIS (F1,429=1.7, p=0.19) was observed. There was a significant upward trend across cohorts in the proportion of referrals treated within 6 months for new EIS (X(2)=8.0, df=1, p=0.005), but not for established EIS (X(2)=0.1, df=1, p=0.72)., Conclusion: The introduction of new EIS was followed by a reduction in DUP and an increase in the proportion of patients treated within 6 months of onset. These trends were not present in the catchment areas of established services where DUP was initially lower, suggesting that there was no general tendency for DUP to fall over time. Hence, the introduction of an EIS was followed by an improvement in the prompt and proper treatment of first episode psychosis., (Copyright © 2014. Published by Elsevier B.V.)

Objective: To investigate the reliability and construct validity of an atlas for grading hand osteoarthritis (OA) on photographs in a separate younger community-dwelling population than the development cohort., Methods: Participants were community-dwelling adults (ages ≥50 years) in North Staffordshire, UK with hand pain or hand problems in the last year who attended a research clinic. High-quality photographs were taken in a standardized position. A photographic atlas was used to score hand joints (second and third distal interphalangeal [DIP], second and third proximal interphalangeal [PIP], and first carpometacarpal [CMC] joints) and joint groups (DIP, PIP, and CMC joints) for OA on a 0-3 scale. Hand radiographs were graded for OA using the Kellgren/Lawrence (K/L) grading system. Clinical features (nodes, bony enlargement, and deformity) were determined by physical examination. Associations of photographic hand OA grades with radiographic OA and clinical features were determined to assess construct validity., Results: In total, 558 participants (mean age 64 years, 62% women) were included in the analyses. Reliability for scoring OA on the photographs was good (mean intrarater intraclass correlation coefficient [ICC] 0.77 and mean interrater ICC 0.71). At the joint level, photographic hand OA grade was positively associated with radiographic OA grade (Spearman's ρ = 0.19-0.57, P < 0.001) and the number of clinical features (Spearman's ρ = 0.36-0.59, P < 0.001). At the person level, individuals with higher global photographic OA scores had higher summed K/L scores and higher percentages meeting the American College of Rheumatology clinical hand OA criteria., Conclusion: This photographic scoring system was reliable and a good indicator of hand OA in a separate younger community-dwelling population than the development cohort. This method of data collection offers researchers a feasible alternative to physical examination and radiography., (© 2014 The Authors. Arthritis Care & Research is published by Wiley Periodicals, Inc. on behalf of the American College of Rheumatology.)

Teamwork and collaboration have been recognized as essential competencies for health care providers in the field of maternity care. Health care policy and regulatory bodies have stressed the importance of Interprofessional Education (IPE) for learners in this field; however, there is little evidence of sustained application of pre-qualifying IPE to the realm of interprofessional collaboration (IPC) in practice following qualification. The aim of this research was to understand how newly qualified midwives applied their IPE training to professional practice. A purposive sample of midwifery students, educators, new midwives and Heads of Midwifery from four universities in the United Kingdom participated in semi-structured interviews, questionnaires and focus groups. Qualitative, grounded theory methodology was used to develop the emerging theory. Newly qualified midwives appeared better able to integrate their IPE training into practice when IPE occurred in a favourable learning environment that facilitated acquisition and application of IPE skills and that recognized the importance of shared partnership between the university and the clinical workplace.

Objective: To investigate in the general population the clinical impact of erosive OA in interphalangeal joints (IPJs) compared with symptomatic radiographic hand OA and inflammatory arthritis., Methods: Standardized assessments with hand radiographs were performed in participants of two population-based cohorts in North Staffordshire with hand symptoms lasting ≥1 day in the past month. Erosive OA was defined as the presence of an eroded or remodelled phase in ≥1 IPJ using the Verbruggen-Veys method. Radiographic hand OA was defined as the presence of ≥1 IPJ/first carpometacarpal joint with a Kellgren-Lawrence score of ≥2. Diagnoses of inflammatory arthritis were based on medical records. Hand pain and disability were assessed with the Australian/Canadian Hand Osteoarthritis Index (AUSCAN). Linear regression analyses were used to compare clinical determinants between groups and calculate mean differences with 95% CIs, adjusted for age and sex., Results: Of 1076 participants with hand symptoms [60% women, mean age 64.8 years (s.d. 8.3 years)]; 80 persons (7.4%) had erosive OA. The population prevalence of erosive OA in ≥1 IPJ was 2.4% (95% CI 1.8, 3.0). Persons with erosive OA reported more pain and disability than persons with symptomatic radiographic hand OA [adjusted mean difference 1.3 (95% CI 0.3, 2.3) and 2.3 (95% CI 0.4, 4.2), respectively]. Individuals with inflammatory arthritis (n = 44) reported more pain and disability than those with erosive OA [adjusted mean difference 1.7 (95% CI 0.05, 3.4) and 6.3 (95% CI 2.8, 9.9), respectively]., Conclusion: While erosive OA has a greater impact than symptomatic radiographic hand OA in the general population, it is not as severe in terms of hand pain and disability as inflammatory RA.

Objective: To compare the population prevalence, inter-relationships, risk factor profiles and clinical characteristics of subsets of symptomatic hand osteoarthritis (OA) with a view to understanding their relative frequency and distinctiveness., Method: 1076 community-dwelling adults with hand symptoms (60% women, mean age 64.7 years) were recruited and classified into pre-defined subsets using physical examination and standardised hand radiographs, scored with the Kellgren & Lawrence (K&L) and Verbruggen-Veys grading systems. Detailed information on selected risk factors was obtained from direct measurement (Body Mass Index (BMI)), self-complete questionnaires (excessive use of hands, previous hand injury) and medical record review (hypertension, dyslipidaemia, type 2 diabetes). Hand pain and disability were self-reported at baseline and 3-year follow-up using Australian/Canadian Osteoarthritis Hand Index (AUSCAN)., Results: Crude population prevalence estimates for symptomatic hand OA subsets in the adult population aged 50 years and over were: thumb base OA (22.4%), nodal interphalangeal joint (IPJ) OA (15.5%), generalised hand OA (10.4%), non-nodal IPJ OA (4.9%), erosive OA (1.0%). Apart from thumb base OA, there was considerable overlap between the subsets. Erosive OA appeared the most distinctive with the highest female: male ratio, and the most disability at baseline and 3-years. A higher frequency of obesity, hypertension, dyslipidaemia, and metabolic syndrome was observed in this subset., Conclusion: Overlap in the occurrence of hand OA subsets poses conceptual and practical challenges to the pursuit of distinct phenotypes. Erosive OA may nevertheless provide particular insight into the role of metabolic and cardiovascular risk factors in the pathogenesis of OA., (Copyright © 2013. Published by Elsevier Ltd.)

Background: Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed., Aims: To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway., Method: Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed., Results: A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP., Conclusions: Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.

Background: The use of compulsory treatment under the Mental Health Act (MHA) has continued to rise in the UK and in other countries. The Joint Crisis Plan (JCP) is a statement of service users' wishes for treatment in the event of a future mental health crisis. It is developed with the clinical team and an independent facilitator. A recent pilot RCT showed a reduction in the use of the MHA amongst service users with a JCP. The JCP is the only intervention that has been shown to reduce compulsory treatment in this way. The CRIMSON trial aims to determine if JCPs, compared with treatment as usual, are effective in reducing the use of the MHA in a range of treatment settings across the UK., Methods/design: This is a 3 centre, individual-level, single-blind, randomised controlled trial of the JCP compared with treatment as usual for people with a history of relapsing psychotic illness in Birmingham, London and Lancashire/Manchester. 540 service users will be recruited across the three sites. Eligible service users will be adults with a diagnosis of a psychotic disorder (including bipolar disorder), treated in the community under the Care Programme Approach with at least one admission to a psychiatric inpatient ward in the previous two years. Current inpatients and those subject to a community treatment order will be excluded to avoid any potential perceived pressure to participate. Research assessments will be conducted at baseline and 18 months. Following the baseline assessment, eligible service users will be randomly allocated to either develop a Joint Crisis Plan or continue with treatment as usual. Outcome will be assessed at 18 months with assessors blind to treatment allocation. The primary outcome is the proportion of service users treated or otherwise detained under an order of the Mental Health Act (MHA) during the follow-up period, compared across randomisation groups. Secondary outcomes include overall costs, service user engagement, perceived coercion and therapeutic relationships. Sub-analyses will explore the effectiveness of the JCP in reducing use of the MHA specifically for Black Caribbean and Black African service users (combined). Qualitative investigations with staff and service users will explore the acceptability of the JCPs., Discussion: JCPs offer a potential solution to the rise of compulsory treatment for individuals with psychotic disorders and, if shown to be effective in this trial, they are likely to be of interest to mental health service providers worldwide., Trial Registration: Current Controlled Trials ISRCTN11501328.

This qualitative study identifies factors influencing the use of substances in young people with recent onset psychosis. A purposive sample of 19 people aged between 16 and 35 years from an Early Intervention Service in the English National Health Service (NHS) was interviewed using a semi-structured guide. All had experienced a psychotic episode and were within 3 years of first contact with the service. All were either currently misusing substances or had been doing so in the 6 months prior to first contact with the service. All participants were/had been regular cannabis users and for 13(68%) cannabis was the primary drug of use. Thematic analysis identified four key themes in participants accounts of factors influencing their substance abuse: influence of perceived drug norms on behaviour; attributions for initial and ongoing drug-taking behaviour; changes in life goals affecting drug use; beliefs about the links between mental health and drug use. These findings have clear implications for interventions at a number of levels to support young people using substances in early psychosis including public health messages, education and psychological therapies., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: Culture and climate represent shared beliefs and values that may influence quality of care in health care teams, and which could be manipulated for quality improvement. However, there is a lack of agreement on the theoretical and empirical relationships between climate and culture, and their relative power as predictors of quality of care. This study sought to examine the association between self-report measures of climate and culture in primary care teams and comprehensive measures of quality of care., Methods: The data were derived from a cross-sectional survey of 492 professionals in 42 general practices in England. Self-report measures of culture (the Competing Values Framework) and climate (the Team Climate Inventory) were used, together with validated measures of quality of care from medical records and self-report., Results: The majority of practices could be characterized as 'clan' culture type. Practices with a dominant clan culture scored higher on climate for participation and teamwork. There were no associations between culture and quality of care, and only limited evidence of associations between climate and quality., Conclusions: The current analysis would not support the hypothesis that culture and climate are important predictors of quality of care in primary care. Although larger studies are required to provide a definitive test, the results may suggest the need for a more complex model of the associations between culture, climate and outcomes, and further research may be required into the interaction between culture and climate with other determinants of behaviour such as internal and external incentives.

Objective: Great importance has been attached to a culture of safe practice in healthcare organisations, but it has proved difficult to engage frontline staff with this complex concept. The present study aimed to develop and test a framework for making the concept of safety culture meaningful and accessible to managers and frontline staff, and facilitating discussion of ways to improve team/organisational safety culture., Setting: Eight primary care trusts and a sample of their associated general practices in north west England., Methods: In phase 1 a comprehensive review of the literature and a postal survey of experts helped identify the key dimensions of safety culture in primary care. Semistructured interviews with 30 clinicians and managers explored the application of these dimensions to an established theory of organisational maturity. In phase 2 the face validity and utility of the framework was assessed in 33 interviews and 14 focus groups., Results: Nine dimensions were identified through which safety culture is expressed in primary care organisations. Organisational descriptions were developed for how these dimensions might be characterised at five levels of organisational maturity. The resulting framework conceptualises patient safety culture as multidimensional and dynamic, and seems to have a high level of face validity and utility within primary care. It aids clinicians' and managers' understanding of the concept of safety culture and promotes discussion within teams about their safety culture maturity., Conclusions: The framework moves the agenda on from rhetoric about the importance of safety culture to a way of understanding why and how the shared values of staff working within a healthcare organisation may be operationalised to create a safe environment for patient care.

Objectives: To investigate how general medical practices in the UK react to bureaucratic initiatives, such as National Health Service (NHS) National Service Frameworks (NSFs), and to explore the value of the metaphor of 'barriers to change' for understanding this., Methods: Interviews, non-participant observation and documentary analysis within case studies of four practices in northern England., Results: The practices had not actively implemented NSFs. At interview, various 'barriers' that had prevented implementation were listed, including the complexity of the documents and lack of time. Observation suggested that these barriers were constructions used by the participants to make sense of the situation in which they found themselves., Conclusion: The metaphor of 'removing barriers to change' was of limited use in a context where non-implementation of policy was an emergent property of underlying organizational realities, likely to be modifiable only if these realities were addressed.

Objective: The publication of information about the performance of health-care providers is regarded as central to promoting greater accountability and empowering patients to exercise choice. The evidence suggests that the public is not very interested in accessing or using current sources of information. This study aimed to explore the information needs of patients in the context of UK primary care and to develop an information source about general practice services, designed to be usable by and useful to patients., Design: An action research study making use of data from formal and informal interviews, focus groups, participant observation and document review., Setting: The geographical areas covered by two Primary Care Trusts in the north of England and two Local Health Boards in south Wales., Participants: A partnership between 103 members of the public, general practice staff from 19 practices, NHS managers from four Primary Care Organizations and the research team., Results: The public would like to know more about the quality and range of general practice services but current sources of information do not meet their needs. The public do not like league tables comparing the performance of practices and only a small number of people want to use comparative information to choose between practices. They seem to be more interested in the context and availability of services and the willingness of practices to improve, than in the practice's absolute or relative performance. They want to be clear about the source of the information so that they can make personal judgements about its veracity. Information is most likely to be useful if it adheres to the basic principles of cognitive science in terms of its structure, content and presentation format. Using these findings, paper and electronic prototype versions of a guide to general practice services have been developed., Conclusions: In order to maximize the potential use of performance information by the public it is necessary to move beyond provider-led and professionally constructed approaches to information provision and ensure that the public is actively involved in the development of information sources. Such involvement produces a different kind of information to that currently available to the public. The findings of this study have important implications for policy. Most importantly, it seems that the traditional consumerist model underlying a policy of making comparative performance information available to the public to enable them to exercise choice between primary care providers may not be appropriate. An alternative model of information provision, which recognizes the public's commitment to their practice and is integrated with 'soft' sources of knowledge is more likely to engage and be of use to the public.

Background: Providing more information for the public about the range and quality of health services is an important part of improving accountability, quality and public responsiveness. Most sources of information to date have failed to address the information needs of people about their local services. The launch in England in 2002 of a new publication, Guides to Local Health Services, was designed to address this deficiency. We conducted an audit of the first Guides, and surveyed those responsible for their production, in order to examine the Guides' development, content, presentation and dissemination, and to critique the purpose of the initiative., Methods: A semi-structured questionnaire survey of those responsible for producing the Guides, and an audit of the Guides produced by Primary Care Trusts (PCTs)., Results: Most PCTs complied with central guidance about structure and content, but in meeting multiple requirements the Guides lost their clarity of purpose. The content was dominated by information relating to financial and strategic accountability. In producing the Guides, external consultation was limited, particularly with the public but also with local partnership providers of health and social care. The main issues were the lack of a clear focus for Guide information, the level of central direction, the short production lead times, difficulties with distribution, and the many competing demands being made on PCT resources., Conclusions: Guide content should be clearly focused on information that the public wants. Greater responsibility should be devolved to front line PCT staff to determine content in consultation with local users.

Objective: To explore some of the impacts of star performance ratings in acute hospital trusts in England., Methods: A multiple case study design was used which incorporated purposeful sampling of 'low' and 'high' performing trusts using the star rating system. In each case study site, data collection comprised semi-structured interviews and documentary analysis. Between eight and 12 senior managers and senior clinicians were interviewed in each organisation., Results: There was a general view that the star ratings as presently constituted did not represent a rounded or balanced scorecard of their own organisation's performance and a widespread belief that the information used to calculate the ratings was often incomplete and inaccurate. The star ratings were viewed by some managers as useful, in that they gave added weight to their trust's modernisation agenda. In addition to driving beneficial change, the ratings were also sometimes reported to have inadvertently induced a range of unintended and dysfunctional consequences, including tunnel vision and a distortion of clinical priorities, bullying and intimidation, erosion of public trust and reduced staff morale, and ghettoisation., Conclusions: Set in the context of an international body of research, this study highlights some important gaps in knowledge and failings in current policy and practice. In particular, the many dysfunctional consequences of publishing star ratings indicate a need for a re-examination of performance management policies.

Objectives: English primary care organisations (primary care groups and trusts - PCGs, PCTs) were, and are, responsible for the quality of general practice but lack hierarchical structures and, frequently, contractual relationships through which to influence it. The theory of soft governance describes how managers can influence professional practice by other means. This study examines the hypothesis that PCG/Ts have used 'soft' clinical governance., Methods: Survey in 2000/01 of general practitioners' (GPs') attitudes, opinions and self-reported activity in six PCGs and six PCTs using a semi-structured mailed questionnaire. To assess how representative respondents were of English GPs generally, four questions from a national sample survey of English GPs were included and the results compared., Results: Responses were obtained from 437 (52%) GPs. They most often mentioned the technical aspects of clinical governance. Managerial, policy and resourcing implications were next most frequently mentioned, usually in unfavourable terms. Most GPs reported that their clinical practice had changed because of clinical governance activities, although nearly 40% also reported little difference in the quality of care provided. The National Service Framework for coronary heart disease influenced practice independently of PCG/T activities., Conclusion: English primary care organisations are exercising soft governance (although not by that name) over some but not all aspects of GPs' clinical practice. However, this soft governance is complex, not easy to sustain and appears hard to extend beyond essentially clinical domains.

Objectives: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care., Design: Qualitative case studies using semi-structured interviews and documentation review., Setting: Twelve purposively sampled PCG/Ts in England., Participants: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members., Main Outcome Measures: Participants' perceptions of the role of clinical governance in PCG/Ts., Results: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment)., Conclusion: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Same-day appointment requests are common and can be problematic for general practices that run appointment systems. In a questionnaire survey sent to 90 general practices in one health authority area (response rate 88%), a variety of management systems existed for dealing with same-day appointment requests. Managing the requests was found to be a significant cause of stress for many general practitioners. Registrars, locums, and practice nurses play only a small part in meeting patient demands and few practices operate telephone triage to help manage these requests.

Background: The professional relationship between GPs and hospital consultants (sometimes referred to as 'specialists') is important in a healthcare system based upon the generalist as the first point of contact for patients and the gate-keeper for hospital services. This relationship has been the subject of considerable interest over the years, but little empirical research., Objectives: We aimed to compare the attitudes of GPs and specialists to key issues, and to produce a validated objective measure of their ability to work together., Methods: We conducted a Likert-style survey based upon statements made in qualitative interviews with GPs and specialists working in the South and West of England. The questionnaire was modified and validated during a multi-stage pilot and was distributed to a stratified random sample of 800 clinicians., Results: GPs and specialists demonstrate a good level of agreement, mutual understanding and respect, though there are significant differences between the two branches of the profession in terms of attitude towards financial parity and direct access to special investigations., Conclusions: A measure of the ability of GPs and specialists to work together has been developed, with acceptable internal consistency and validity. It may be used in other geographical areas to assess a relationship which is central to the efficient and effective operation of the National Health Service.

Background: The professional relationship between general practitioners (GPs) and hospital consultants (sometimes referred to as 'specialists') is important in a health care system based upon the generalist as the first point of contact for patients and the gatekeeper for hospital services. This relationship has been the subject of considerable interest over the years, but little empirical research has been carried out., Aim: To investigate the professional relationship in terms of the balance between cooperation and conflict between GPs and specialists in clinical contact., Method: A qualitative study using 24 semistructured interviews and four focus group interviews with a purposeful sample of clinicians working in the south-west of England. A content analysis of the data was performed., Results: There is a high level of mutual respect and cooperation between the two branches of the profession and a strong desire to build a personal relationship over a long period of time. There are few areas of significant disagreement; indeed, most members of both branches of the profession try hard to deal with, or avoid, potential conflict., Conclusion: The professional relationship between GPs and specialists is better than the literature and anecdotal stories might suggest.

Background and Objective: This article considers the role of the key informant technique as a qualitative research method and examines the potential contribution of the approach to health care research., Method: The principles underlying the technique and the advantages and disadvantages are considered, illustrated with examples from a range of social science studies., Results and Conclusion: An example of the author's own use of key informants in a study of the professional relationship between general practitioners and specialists is described.

Objectives: To follow up severely mentally ill residents of hostels for the homeless to determine their social and psychiatric outcome., Design: Follow up at 18 months of hostel residents previously assessed with psychiatric and behavioural measures., Setting: Two Oxford hostels for the homeless., Subjects: 48 hostel residents previously identified as disabled by mental illness., Main Outcome Measures: Current housing, admissions to psychiatric hospital, violent or antisocial behaviour, and score on standardised behavioural rating., Results: 45 of the 48 residents were traced. 27 had remained in the hostels; only 10 had been rehoused, mainly in bedsits or with their families. 16 had a poor outcome as judged by death (four subjects), lengthy hospital readmission (two), marked deterioration in behaviour (six), sleeping rough (one), or disappearance (three)., Conclusion: More effort is needed to provide suitable housing for homeless mentally ill people.

Objective: To assess the severity of psychiatric symptoms among residents of hostels for homeless people., Design: Survey of residents in two hostels in Oxford, comprising three weeks of background fieldwork, a demographic questionnaire, and rating behaviour over two weeks with a behavioural rating scale (REHAB) and mental state with the brief psychiatric rating scale., Setting: Two hostels for homeless people in Oxford., Subjects: 146 Medium to long term residents, of whom 48 were selected by hostel workers by the following criteria: continuous residence for at least two months, signs of persistent severe mental disability, and difficulty in coping independently in the community. Two subjects died during the study; three (previously long term psychiatric inpatients) declined to be assessed on the psychiatric scale., Main Outcome Measure: Behavioural disturbance and mental state., Results: Only a third of the total sample had been born in Oxfordshire. Subjects had been accepted into the hostel either by arrangement with the local psychiatric service (22) or straight off the streets (26); 43 had had a previous (non-drug related) psychiatric admission. Subjects were significantly more likely than other residents to have spent longer (greater than 80 weeks) in a hostel in the past three years (p less than 0.02). With reference to norms for deviant behaviour, the 46 subjects assessed showed considerable deviant behaviour (average weekly scores: 0 (11 subjects), 1 (14), 2-3 (16), and greater than or equal to 4 (5] not significantly different from that expected in moderately to severely handicapped psychiatric inpatients (chi 2 = 1.3, df = 3, p greater than 0.7); 22 had scores equivalent to those in most severely handicapped inpatients. Of the 43 subjects assessed with the psychiatric rating scale, 16 had symptoms of neurosis, 29 of florid psychosis, and 32 of a deficit state. Symptoms of deficit state were positively correlated with ratings of low social activity on the behavioural scale (Spearman's rank correlation coefficient 0.30, p = 0.03)., Conclusions: Hostels are having to care for long term severely affected psychiatric patients discharged into the community. The suitability of the services offered to such subjects should be assessed.