National evaluation of NHS genetics service investments: emerging issues from the cancer genetics pilots

In seeking to fulfil the ambition of the 2003 genetics white paper, Our Inheritance, Our Future, to ‘mainstream’ genetic knowledge and practices, the Department of Health provided start-up funding for pilot services in various clinical areas, including seven cancer genetics projects. To help to understand the challenges encountered by such an attempt at reconfiguring the organization and delivery of services in this field, a programme-level evaluation of the genetics projects was commissioned to consider the organizational issues faced. Using a qualitative approach, this research has involved comparative case-study work in 11 of the pilot sites, including four of the seven cancer genetics pilots. In this paper, the researchers present early findings from their work, focusing in particular on the cancer genetics pilots. They consider some of the factors that have influenced how the pilots have sought to address pre-existing sector, organizational and professional boundaries to these new ways of working. The article examines the relationship between these factors and the extent to which pilots have succeeded in setting up boundary-spanning services, dealing with human-resource issues and creating sustainable, ‘mainstreamed’ provision which attracts ongoing funding in a volatile NHS commissioning environment where funding priorities do not always favour preventive, risk-assessment services.

A Utilitarian Perspective of Social and Medical Contributions to Three Illustrative Conditions, and Recent UK NHS Policy Initiatives

Background: To date debate concerning the relative merits of social and medical sciences has been largely academic. Aims: To outline and critically appraise a utilitarian approach to mental health research that reflects a critical realist perspective. Method: Consideration of the relative utility of differing approaches to illustrative ‘‘psychiatric’’ disorders, and recent policy initiatives. Results: Socially relevant outcomes of Bipolar Affective Disorder are determined by influences that operate independently of the characteristic instability of mood. There is now a highly specific and effective psychological treatment for Panic Disorder. Its benefits are still not fully exploited because of continuing lay and professional focus upon the condition’s social manifestations. Great numbers of people presenting in primary care are unhelpfully caused to adopt the role of ‘‘patient’’ due to practices limiting the professional response to a medical one. Such practices reflect public and professional perceptions of the nature of ‘‘mental health difficulties’’ much more than they do the achievements of medicine. Recent policy-supporting initiatives influencing UK NHS mental health services are much more likely to be supported by social sciences than by medical research. Conclusions: There is considerable scope for a contribution to applied mental health research from frameworks and methodologies that are rooted in a social sciences perspective.

Whose health, whose care, whose say? Some comments on public involvement in new NHS commissioning arrangements

Recent health policy in England has demanded greater involvement of patients and the public in the commissioning of health and social care services. Public involvement is seen as a means of driving up service quality, reducing health inequalities and achieving value in commissioning decisions. This paper presents a summary and analysis of the forms that public involvement in commissioning are to take, along with empirical analysis from a qualitative study of service-user involvement. It is argued that the diversity of constituencies covered by the notion of ‘public involvement’, and the breadth of aims that public involvement is expected to achieve, require careful disaggregation. Public involvement in commissioning may encompass a variety of interest groups, whose inputs may include population needs assessment, evaluation of service quality, advocacy of the interests of a particular patient group or service, or a combination of all of these. Each of these roles may be legitimate, but there are significant tensions between them. The extent to which the structures for public involvement proposed recognize these possible tensions is arguably limited. Notably, new Local Involvement Networks (LINks), which will feed into commissioning decisions, are set as the arbiters of these different interests, a demanding role which will require considerable skill, tenacity and robustness if it is to be fulfilled effectively.

The dynamics of professions and development of new roles in public services organizations: the case of modern matrons in the English NHS

This study contributes to research examining how professional autonomy and hierarchy impacts upon the implementation of policy designed to improve the quality of public services delivery through the introduction of new managerial roles. It is based on an empirical examination of a new role for nurses – modern matrons – who are expected by policy-makers to drive organizational change aimed at tackling health care acquired infections (HCAI) in the National Health Service (NHS) within England. First, we show that the changing role of nurses associated with their ongoing professionalization limits the influence of modern matrons over their own ranks in tackling HCAI. Second, the influence of modern matrons over doctors is limited. Third, government policy itself appears inconsistent in its support for the role of modern matrons. The attempts of modern matrons to tackle HCAI appear more effective where infection control activity is situated in professional practice and where modern matrons integrate aspirations for improved infection control within mainstream audit mechanisms in a health care organization.

Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services

BACKGROUND: Improving the quality of health care services requires tailoring facilities to fulfil patients' needs. Satisfying patients' healthcare needs, listening to patients' opinions and building a closer provider-user partnership are central to the NHS. Few published studies have discussed cardiovascular patients' health needs, but they are not comprehensive and fail to explore the contribution of outcome to needs assessment. METHOD: A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients admitted to the Acute Cardiac Unit, Nottingham. RESULTS: 38% reported difficulty accessing health facilities, 56% due to transport and 32% required a travelling companion. Mean HRQOL scores were lower in those living alone (P < 0.05) or who reported unsatisfactory accommodation. Dissatisfaction with transport affected patients' ease of access to healthcare facilities (P < 0.001). Younger patients (<65 y) were more likely to be socially isolated (P = 0.01). Women and patients with chronic disease were more likely to be concerned about housework (P < 0.05). Over 65 s (p < 0.05) of higher social classes (p < 0.01) and greater physical needs (p < 0.001) had more social needs, correlating moderately (0.32 < r < 0.63) with all HRQL domains except SAQ-AS. Several HRQL components were highly correlated with the HNA physical score (p < 0.001). CONCLUSIONS: Patients wanted more social (suitable accommodation, companionship, social visits) and physical (help aids, access to healthcare services, house work) support. The construct validity and intra-class reliability of the HNA tool were confirmed. Our results indicate a gap between patients' health needs and available services, highlighting potential areas for improvement in the quality of services

Prophylactic antibiotics for the prevention of cellulitis

Background: Cellulitis of the lower leg accounts for 2-3% of hospital admissions (Cox et al, 1998), with an average length of in-patient stay of nine days. Studies have reported that up to half of these patients suffer further episodes (Cox et al, 1998; Dupuy et al, 1999). Reducing the recurrence of cellulitis could therefore have a significant impact on both patient morbidity and NHS costs. Aims: To assess whether prophylactic antibiotics prescribed after an episode of cellulitis of the leg results in fewer subsequent attacks and reduced health service costs (PATCH prophylactic antibiotics for the treatment of cellulitis at home). Methods: This article describes two related studies in which participants are randomised to receive either 12 months of prophylaxis (PATCH I) or six months of prophylaxis (PATCH II). The PATCH I study recruits only patients with recurrent disease defined as two or more episodes of cellulitis in the last three years. PATCH II has more open criteria and includes patients with a first episode of cellulitis and also participants with recurrent disease. It is expected that 260 patients will be recruited into PATCH I and 400 patients into PATCH II.

Human motivation and professional practice: of knights, knaves and social workers

Efforts to improve the efficiency and responsiveness of public services by harnessing the self-interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social services, one way in which British policy-makers have sought to effect such changes has been through the "new community care" of the 1990 NHS and Community Care Act. Key to this is the concept of care management, in which the identification of needs and the provision of services are separated, purportedly with a view to improving advocacy, choice and quality for service users. This paper uses data from a wide-ranging qualitative study of access to social care for older people to examine the success of the policy in these terms, with specific reference to its attempts to harness the rational self-interest of professionals. While care management removes one potential conflict of interests by separating commissioning and provision, the responsibility of social care professionals to comply with organizational priorities conflicts with their role of advocacy for their clients, a tension rendered all the more problematic by the perceived inadequacy of funding. Moreover, the bureaucracy of the care management process itself further negates the approach's supposedly client-centred ethos. The definitive version is available at www.blackwell-synergy.com

The organization, form and function of intermediate care services and systems in England: results from a national survey

This paper reports the results of a postal survey of intermediate care co-ordinators (ICCs) on the organization and delivery of intermediate care services for older people in England, conducted between November 2003 and May 2004. Questionnaires, which covered a range of issues with a variety of quantitative, ‘tick-box’ and open-ended questions, were returned by 106 respondents, representing just over 35% of primary care trusts (PCTs). We discuss the role of ICCs, the integration of local systems of intermediate care provision, and the form, function and model of delivery of services described by respondents. Using descriptive and statistical analysis of the responses, we highlight in particular the relationship between provision of admission avoidance and supported discharge, the availability of 24-hour care, and the locations in which care is provided, and relate our findings to the emerging evidence base for intermediate care, guidance on implementation from central government, and debate in the literature. Whilst the expansion and integration of intermediate care appear to be continuing apace, much provision seems concentrated in supported discharge services rather than acute admission avoidance, and particularly in residential forms of post-acute intermediate care. Supported discharge services tend to be found in residential settings, while admission avoidance provision tends to be non-residential in nature. Twenty-four hour care in non-residential settings is not available in several responding PCTs. These findings raise questions about the relationship between the implementation of intermediate care and the evidence for and aims of the policy as part of NHS modernization, and the extent to which intermediate care represents a genuinely novel approach to the care and rehabilitation of older people.

Adaptive regulation or governmentality: patient safety and the changing regulation of medicine

Studies from across the world have shown that clinical mistakes are a major threat to the safety of patient care (World Health Organisation 2004). For the National Health Service (NHS) of England and Wales it is estimated that one in ten hospital patients experience some form of error, and each year these cost the service over £2billion in remedial care (Department of Health 2000). Unsurprisingly, ‘patient safety’ is now a major international health policy priority, questioning the efficacy of existing regulatory practices and proposing a new ethos of learning. Within England and Wales, the National Patient Safety Agency (NPSA) has been created to lead policy development and champion service-wide learning, whilst throughout the NHS the National Reporting and Learning System (NRLS) has been introduced to enable this learning (NPSA 2003). This paper investigates the extent to which, in seeking to better manage the threats to patient safety, this policy agenda represents a transition in medical regulation.

Doctors' thinking about the system as a threat to patient safety

‘Systems thinking’ is an important feature of the emerging ‘patient safety’ agenda. As a key component of a ‘safety culture’, it encourages clinicians to look past individual error to recognise the latent factors that threaten safety. This paper investigates whether current medical thinking is commensurate with the idea of ‘systems thinking’ together with its implications for policy. The findings are based on qualitative semistructured interviews with specialist physicians working within one NHS District General Hospital in the English Midlands. It is shown that, rather then favouring a 'person-centred’ perspective, doctors readily identify ‘the system’ as a threat to patient safety. This is not necessarily a reflection of the prevailing safety discourse or knowledge of policy, but reflects a tacit understanding of how services are (dis)organised. This line of thinking serves to mitigate individual wrong-doing and protect professional credibility by encouraging doctors to accept and accommodate the shortcomings of the system, rather than participate in new forms of organisational learning.

Introducing the National Library for Health Skin Conditions Specialist Library

Background: This paper introduces the new National Library for Health Skin Conditions Specialist Library http://www.library.nhs.uk/skin. Description: The aims, scope and audience of the new NLH Skin Conditions Specialist Library, and the composition and functions of its core Project Team, Editorial Team and Stakeholders Group are described. The Library's collection building strategy, resource and information types, editorial policies, quality checklist, taxonomy for content indexing, organisation and navigation, and user interface are all presented in detail. The paper also explores the expected impact and utility of the new Library, as well as some possible future directions for further development. Conclusion: The Skin Conditions Specialist Library is not just another new Web site that dermatologists might want to add to their Internet favourites then forget about it. It is intended to be a practical, "one-stop shop" dermatology information service for everyday practical use, offering high quality, up-to-date resources, and adopting robust evidence-based and knowledge management approaches.