Policy entrepreneurship in the development of public sector strategy: the case of London health reform

The development of health policy is recognized as complex; however, there has been little development of the role of agency in this process. Kingdon developed the concept of policy entrepreneur (PE) within his ‘windows’ model. He argued inter-related ‘policy streams' must coincide for important issues to become addressed. The conjoining of these streams may be aided by a policy entrepreneur. We contribute by clarifying the role of the policy entrepreneur and highlighting the translational processes of key actors in creating and aligning policy windows. We analyse the work in London of Professor Sir Ara Darzi as a policy entrepreneur. An important aspect of Darzi's approach was to align a number of important institutional networks to conjoin related problems. Our findings highlight how a policy entrepreneur not only opens policy windows but also yokes together a network to make policy agendas happen. Our contribution reveals the role of clinical leadership in health reform.

Unity in diversity: electronic patient record use in multidisciplinary practice

In this paper we examine the use of electronic patient records (EPR) by clinical specialists in their development of multidisciplinary care for diagnosis and treatment of breast cancer. We develop a practice theory lens to investigate EPR use across multidisciplinary team practice. Our findings suggest that there are oppositional tendencies towards diversity in EPR use and unity which emerges across multidisciplinary work, and this influences the outcomes of EPR use. The value of this perspective is illustrated through the analysis of a year-long, longitudinal case study of a multidisciplinary team of surgeons, oncologists, pathologists, radiologists, and nurse specialists adopting a new EPR. Each group adapted their use of the EPR to their diverse specialist practices, but they nonetheless orientated their use of the EPR to each others' practices sufficiently to support unity in multidisciplinary teamwork. Multidisciplinary practice elements were also reconfigured in an episode of explicit negotiations, resulting in significant changes in EPR use within team meetings. Our study contributes to the growing literature that questions the feasibility and necessity of achieving high levels of standardized, uniform health information technology use in healthcare.

Air quality and public health impacts of UK airports. Part I: Emissions

The potential adverse human health and climate impacts of emissions from UK airports have become a significant political issue, yet the emissions, air quality impacts and health impacts attributable to UK airports remain largely unstudied. We produce an inventory of UK airport emissions - including aircraft landing and takeoff (LTO) operations and airside support equipment - with uncertainties quantified. The airports studied account for more than 95% of UK air passengers in 2005. We estimate that in 2005, UK airports emitted 10.2 Gg [-23 to +29%] of NOx, 0.73 Gg [-29 to +32%] of SO2, 11.7 Gg [-42 to +77%] of CO, 1.8 Gg [-59 to +155%] of HC, 2.4 Tg [-13 to +12%] of CO2, and 0.31 Gg [-36 to +45%] of PM2.5. This translates to 2.5 Tg [-12 to +12%] CO2-eq using Global Warming Potentials for a 100-year time horizon. Uncertainty estimates were based on analysis of data from aircraft emissions measurement campaigns and analyses of aircraft operations.The First-Order Approximation (FOA3) - currently the standard approach used to estimate particulate matter emissions from aircraft - is compared to measurements and it is shown that there are discrepancies greater than an order of magnitude for 40% of cases for both organic carbon and black carbon emissions indices. Modified methods to approximate organic carbon emissions, arising from incomplete combustion and lubrication oil, and black carbon are proposed. These alterations lead to factor 8 and a 44% increase in the annual emissions estimates of black and organic carbon particulate matter, respectively, leading to a factor 3.4 increase in total PM2.5 emissions compared to the current FOA3 methodology. Our estimates of emissions are used in Part II to quantify the air quality and health impacts of UK airports, to assess mitigation options, and to estimate the impacts of a potential London airport expansion. © 2011 Elsevier Ltd.

Methodological implications of critical realism for mixed-methods research

Building on recent developments in mixed methods, we discuss the methodological implications of critical realism and explore how these can guide dynamic mixed-methods research design in information systems. Specifically, we examine the core ontological assumptions of CR in order to gain some perspective on key epistemological issues such as causation and validity, and illustrate how these shape our logic of inference in the research process through what is known as retroduction. We demonstrate the value of a CR-led mixed-methods research approach by drawing on a study that examines the impact of ICT adoption in the financial services sector. In doing so, we provide insight into the interplay between qualitative and quantitative methods and the particular value of applying mixed methods guided by CR methodological principles. Our positioning of demi-regularities within the process of retroduction contributes a distinctive development in this regard. We argue that such a research design enables us to better address issues of validity and the development of more robust meta-inferences.

Leadership of healthcare commissioning networks in England: a mixed-methods study on clinical commissioning groups.

To explore the relational challenges for general practitioner (GP) leaders setting up new network-centric commissioning organisations in the recent health policy reform in England, we use innovation network theory to identify key network leadership practices that facilitate healthcare innovation.

Policy as a struggle for meaning: disentangling knowledge translation across international health contexts

Over the last decade, research in medical science has focused on knowledge translation and diffusion of best practices to enable improved health outcomes. However, there has been less attention given to the role of policy in influencing the translation of best practice across different national contexts. This paper argues that the underlying set of public discourses of healthcare policy significantly influences its development with implications for the dissemination of best practices. Our research uses Critical Discourse Analysis to examine the policy discourses surrounding the treatment of stroke across Canada and the U.K. It focuses in specific on how concepts of knowledge translation, user empowerment, and service innovation construct different accounts of the health service in the two countries. These findings provide an important yet overlooked starting point for understanding the role of policy development in knowledge transfer and the translation of science into health practice. © 2011 Operational Research Society. All rights reserved.

Global civil aviation black carbon emissions.

Aircraft black carbon (BC) emissions contribute to climate forcing, but few estimates of BC emitted by aircraft at cruise exist. For the majority of aircraft engines the only BC-related measurement available is smoke number (SN)-a filter based optical method designed to measure near-ground plume visibility, not mass. While the first order approximation (FOA3) technique has been developed to estimate BC mass emissions normalized by fuel burn [EI(BC)] from SN, it is shown that it underestimates EI(BC) by >90% in 35% of directly measured cases (R(2) = -0.10). As there are no plans to measure BC emissions from all existing certified engines-which will be in service for several decades-it is necessary to estimate EI(BC) for existing aircraft on the ground and at cruise. An alternative method, called FOX, that is independent of the SN is developed to estimate BC emissions. Estimates of EI(BC) at ground level are significantly improved (R(2) = 0.68), whereas estimates at cruise are within 30% of measurements. Implementing this approach for global civil aviation estimated aircraft BC emissions are revised upward by a factor of ~3. Direct radiative forcing (RF) due to aviation BC emissions is estimated to be ~9.5 mW/m(2), equivalent to ~1/3 of the current RF due to aviation CO2 emissions.

Updated correlation between aircraft smoke number and black carbon concentration

Aircraft emissions of black carbon (BC) contribute to anthropogenic climate forcing and degrade air quality. The smoke number (SN) is the current regulatory measure of aircraft particulate matter emissions and quantifies exhaust plume visibility. Several correlations between SN and the exhaust mass concentration of BC (CBC) have been developed, based on measurements relevant to older aircraft engines. These form the basis of the current standard method used to estimate aircraft BC emissions (First Order Approximation version 3 [FOA3]) for the purposes of environmental impact analyses. In this study, BC with a geometric mean diameter (GMD) of 20, 30, and 60 nm and filter diameters of 19 and 35 mm are used to investigate the effect of particle size and sampling variability on SN measurements. For BC with 20 and 30 nm GMD, corresponding to BC emitted by modern aircraft engines, a smaller SN results from a given CBC than is the case for BC with 60 nm GMD, which is more typical of older engines. An updated correlation between CBC and SNthat accounts for typical size of BC emitted by modern aircraft is proposed. An uncertainty of ±25% accounts for variation in GMD in the range 20-30 nm and for the range of filter diameters. The SN-CBC correlation currently used in FOA3 underestimates by a factor of 2.5-3 for SN <15, implying that current estimates of aircraft BC emissions derived from SN are underestimated by the same factor. Copyright © American Association for Aerosol Research.