Culture and behaviour in the English National Health Service:overview of lessons from a large multimethod study

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.

Impact of denial of service solutions on network quality of service

The Internet has become a universal communication network tool. It has evolved from a platform that supports best-effort traffic to one that now carries different traffic types including those involving continuous media with quality of service (QoS) requirements. As more services are delivered over the Internet, we face increasing risk to their availability given that malicious attacks on those Internet services continue to increase. Several networks have witnessed denial of service (DoS) and distributed denial of service (DDoS) attacks over the past few years which have disrupted QoS of network services, thereby violating the Service Level Agreement (SLA) between the client and the Internet Service Provider (ISP). Hence DoS or DDoS attacks are major threats to network QoS. In this paper we survey techniques and solutions that have been deployed to thwart DoS and DDoS attacks and we evaluate them in terms of their impact on network QoS for Internet services. We also present vulnerabilities that can be exploited for QoS protocols and also affect QoS if exploited. In addition, we also highlight challenges that still need to be addressed to achieve end-to-end QoS with recently proposed DoS/DDoS solutions. © 2010 John Wiley & Sons, Ltd.