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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. [ABSTRACT FROM AUTHOR]

Summary: A rare case of arterio‐biliary fistula and haemobilia complicating intra‐operative microwave ablation of hepatocellular carcinoma in a 58‐year‐old woman with cirrhosis. [ABSTRACT FROM AUTHOR]

This paper contributes to the literature on ethics in Participatory Research by looking at the Researcher-in-Residence model and its application within health services research in three East London boroughs. The Researcher-in-Residence is embedded in the organisation to enable knowledge mobilisation and knowledge coproduction. Whereas negotiation of different types of expertise to coproduce evidence might raise issues of power differentials, the embedded nature of the role also requires careful negotiating of relationships. As the researcher is immersed in the context under evaluation, the boundaries between the researcher and the participants' everyday working life can become blurred. The paper explores these ethical issues and suggests that, whereas the requirements of ethics committees, based on an ethics of principle, at times fail to offer appropriate guidelines for this methodological approach, an ethics of care based on relationships can offer a complementary framework to address some of the thorny challenges that emerge from everyday practice in participatory research. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in a rapid change in workload across healthcare systems. Factors related to this adaptation in UK primary care have not yet been examined.Aim: To assess the responsiveness and prioritisation of primary care consultation type for older adults during the COVID-19 pandemic.Design and Setting: A cross-sectional database study examining consultations between 17 February and 10 May 2020 for patients aged ≥65 years, drawn from primary care practices within the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) sentinel network, UK.Method: The authors reported the proportion of consultation type across five categories: clinical administration, electronic/video, face-to-face, telephone, and home visits. Temporal trends in telephone and face-to-face consultations were analysed by polypharmacy, frailty status, and socioeconomic group using incidence rate ratios (IRR).Results: Across 3 851 304 consultations, the population median age was 75 years (interquartile range [IQR] 70-82); and 46% (n = 82 926) of the cohort (N = 180 420) were male. The rate of telephone and electronic/video consultations more than doubled across the study period (106.0% and 102.8%, respectively). Face-to-face consultations fell by 64.6% and home visits by 62.6%. This predominantly occurred across week 11 (week commencing 9 March 2020), coinciding with national policy change. Polypharmacy and frailty were associated with a relative increase in consultations. The greatest relative increase was among people taking ≥10 medications compared with those taking none (face-to-face IRR 9.90, 95% CI = 9.55 to 10.26; telephone IRR 17.64, 95% CI = 16.89 to 18.41).Conclusion: Primary care has undergone an unprecedented in-pandemic reorganisation while retaining focus on patients with increased complexity. [ABSTRACT FROM AUTHOR]

Purpose: Organisational Development (OD), with its focus on partnership working and distributed leadership, is increasingly advocated as an effective approach to driving change. Our evaluation of the impact of OD on delivery of integrated care in three London boroughs sheds light on how OD is being understood and implemented within health services, and what impact it is having on delivery of care.Design/methodology/approach: The findings presented here are based on a qualitative and participatory evaluation. The authors looked at how health and social care professionals communicated and coordinated delivery of care and evaluated the impact of current OD activities on the ground to evidence whether and to which degree they are enabling frontline staff to change their working routines towards greater coordination.Findings: Our findings highlight the limited reach and scope of a top-down approach to OD based on ad hoc coaching and staff engagement events, often delivered by external consultancies, and mostly focused at the senior management level. This approach fell short of enabling the creation of sustainable, integrated and collaborative organisations. Instead, some of the professionals that participated in our study tried to develop spaces that facilitated ongoing dialogue and mutual support among professionals on the ground.Practical Implications: Initiatives of bottom-up OD such as those described in this paper have greater potential to change working routines as they enable staff to move towards more collaborative and coordinated work.Originality/value: These findings contribute to the literature on OD in public services and highlight the benefits of a context-sensitive, pragmatic, and long-term approach to OD to help create sustainable collaborative organisations. [ABSTRACT FROM AUTHOR]

Background: Health services have failed to respond to the pressures of multimorbidity. Improved measures of multimorbidity are needed for conducting research, planning services and allocating resources.Methods: We modelled the association between 37 morbidities and 3 key outcomes (primary care consultations, unplanned hospital admission, death) at 1 and 5 years. We extracted development (n = 300 000) and validation (n = 150 000) samples from the UK Clinical Practice Research Datalink. We constructed a general-outcome multimorbidity score by averaging the standardized weights of the separate outcome scores. We compared performance with the Charlson Comorbidity Index.Results: Models that included all 37 conditions were acceptable predictors of general practitioner consultations (C-index 0.732, 95% confidence interval [CI] 0.731-0.734), unplanned hospital admission (C-index 0.742, 95% CI 0.737-0.747) and death at 1 year (C-index 0.912, 95% CI 0.905-0.918). Models reduced to the 20 conditions with the greatest combined prevalence/weight showed similar predictive ability (C-indices 0.727, 95% CI 0.725-0.728; 0.738, 95% CI 0.732-0.743; and 0.910, 95% CI 0.904-0.917, respectively). They also predicted 5-year outcomes similarly for consultations and death (C-indices 0.735, 95% CI 0.734-0.736, and 0.889, 95% CI 0.885-0.892, respectively) but performed less well for admissions (C-index 0.708, 95% CI 0.705-0.712). The performance of the general-outcome score was similar to that of the outcome-specific models. These models performed significantly better than those based on the Charlson Comorbidity Index for consultations (C-index 0.691, 95% CI 0.690-0.693) and admissions (C-index 0.703, 95% CI 0.697-0.709) and similarly for mortality (C-index 0.907, 95% CI 0.900-0.914).Interpretation: The Cambridge Multimorbidity Score is robust and can be either tailored or not tailored to specific health outcomes. It will be valuable to those planning clinical services, policymakers allocating resources and researchers seeking to account for the effect of multimorbidity. [ABSTRACT FROM AUTHOR]

Purpose: This scoping review explores what is known about the role of organizational and professional cultures in medication safety. The aim is to increase our understanding of 'cultures' within medication safety and provide an evidence base to shape governance arrangements.Data Sources: Databases searched are ASSIA, CINAHL, EMBASE, HMIC, IPA, MEDLINE, PsycINFO and SCOPUS.Study Selection: Inclusion criteria were original research and grey literature articles written in English and reporting the role of culture in medication safety on either organizational or professional levels, with a focus on nursing, medical and pharmacy professions. Articles were excluded if they did not conceptualize what was meant by 'culture' or its impact was not discussed.Data Extraction: Data were extracted for the following characteristics: author(s), title, location, methods, medication safety focus, professional group and role of culture in medication safety.Results Of Data Synthesis: A total of 1272 citations were reviewed, of which, 42 full-text articles were included in the synthesis. Four key themes were identified which influenced medication safety: professional identity, fear of litigation and punishment, hierarchy and pressure to conform to established culture. At times, the term 'culture' was used in a non-specific and arbitrary way, for example, as a metaphor for improving medication safety, but with little focus on what this meant in practice.Conclusions: Organizational and professional cultures influence aspects of medication safety. Understanding the role these cultures play can help shape both local governance arrangements and the development of interventions which take into account the impact of these aspects of culture. [ABSTRACT FROM AUTHOR]

The BMA report included recommendations based on the findings from a survey of 2000 BMA members carried out to understand the specific challenges faced by doctors working through the menopause. BMS, RCOG, RCGP, FSRH, FOM and FPH Position Statement in response to the BMA report "Challenging the culture on menopause for doctors" - August 2020 Graph This Statement was endorsed by the Academy of Medical Royal Colleges Graph The British Menopause Society (BMS), Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of General Practitioners (RCGP), Faculty of Sexual and Reproductive Healthcare (FSRH), Faculty of Occupational Medicine (FOM) and the Faculty of Public Health (FPH) have issued this Position Statement in response to the British Medical Association's (BMA) report "Challenging the culture on menopause for doctors" published on 6 August 2020. [Extracted from the article]

Group clinics are becoming popular as a new care model in diabetes care. This evidence synthesis, using realist review methodology, examined the role of group clinics in meeting the complex needs of young people living with diabetes. Following Realist And Meta-narrative Evidence Synthesis-Evolving Standards (RAMESES) quality standards, we conducted a systematic search across 10 databases. A total of 131 articles met inclusion criteria and were analyzed to develop theoretically informed explanations of how and why group clinics could work (or not) for young people with diabetes. Models of group-based care in the literature varied significantly and incorporated different degrees of clinical and educational content. Our analysis identified four overarching principles that can be applied in different contexts to drive sustained engagement of young people in group clinics: 1) emphasizing self-management as practical knowledge; 2) developing a sense of affinity between patients; 3) providing safe, developmentally appropriate care; and 4) balancing group and individual needs. Implementation of group clinics was not always straightforward; numerous adjustments to operational and clinical processes were required to establish and deliver high-quality care. Group clinics for young people with diabetes offer the potential to complement individualized care but are not a panacea and may generate as well as solve problems. [ABSTRACT FROM AUTHOR]

Background: Patient and public involvement (PPI) continues to develop as a central policy agenda in health care. The patient voice is seen as relevant, informative and can drive service improvement. However, critical exploration of PPI's role within monitoring and informing medical performance processes remains limited. Objective: To explore and evaluate the contribution of PPI in medical performance processes to understand its extent, purpose and process. Search strategy: The electronic databases PubMed, PsycINFO and Google Scholar were systematically searched for studies published between 2004 and 2018. Inclusion criteria: Studies involving doctors and patients and all forms of patient input (eg, patient feedback) associated with medical performance were included. Data extraction and synthesis: Using an inductive approach to analysis and synthesis, a coding framework was developed which was structured around three key themes: issues that shape PPI in medical performance processes; mechanisms for PPI; and the potential impacts of PPI on medical performance processes. Main results: From 4772 studies, 48 articles (from 10 countries) met the inclusion criteria. Findings suggest that the extent of PPI in medical performance processes globally is highly variable and is primarily achieved through providing patient feedback or complaints. The emerging evidence suggests that PPI can encourage improvements in the quality of patient care, enable professional development and promote professionalism. Discussion and conclusions: Developing more innovative methods of PPI beyond patient feedback and complaints may help revolutionize the practice of PPI into a collaborative partnership, facilitating the development of proactive relationships between the medical profession, patients and the public. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The concept of knowledge co-production is used in health services research to describe partnerships (which can involve researchers, practitioners, managers, commissioners or service users) with the purpose of creating, sharing and negotiating different knowledge types used to make improvements in health services. Several knowledge co-production models have been proposed to date, some involving intermediary roles. This paper explores one such model, researchers-in-residence (also known as 'embedded researchers'). In this model, researchers work inside healthcare organisations, operating as staff members while also maintaining an affiliation with academic institutions. As part of the local team, researchers negotiate the meaning and use of research-based knowledge to co-produce knowledge, which is sensitive to the local context. Even though this model is spreading and appears to have potential for using co-produced knowledge to make changes in practice, a number of challenges with its use are emerging. These include challenges experienced by the researchers in embedding themselves within the practice environment, preserving a clear focus within their host organisations and maintaining academic professional identity. In this paper, we provide an exploration of these challenges by examining three independent case studies implemented in the UK, each of which attempted to co-produce relevant research projects to improve the quality of care. We explore how these played out in practice and the strategies used by the researchers-inresidence to address them. In describing and analysing these strategies, we hope that participatory approaches to knowledge co-production can be used more effectively in the future. [ABSTRACT FROM AUTHOR]

Introduction: Reflective practice has become the cornerstone of continuing professional development for doctors, with the expectation that it helps to develop and sustain the workforce for patient benefit. Annual appraisal is mandatory for all practicing doctors in the United Kingdom as part of medical revalidation. Doctors submit a portfolio of supporting information forming the basis of their appraisal discussion where reflection on the information is mandated and evaluated by a colleague, acting as an appraiser. Methods: Using an in-depth case study approach, 18 online portfolios in Scotland were examined with a template developed to record the types of supporting information submitted and how far these showed reflection and/or changes to practice. Data from semistructured interviews with the doctors (n = 17) and their appraisers (n = 9) were used to contextualize and broaden our understanding of the portfolios. Results: Portfolios generally showed little written reflection, and most doctors were unenthusiastic about documenting reflective practice. Appraisals provided a forum for verbal reflection, which was often detailed in the appraisal summary. Portfolio examples showed that reflecting on continued professional development, audits, significant events, and colleague multisource feedback were sometimes considered to be useful. Reflecting on patient feedback was seen as less valuable because feedback tended to be uncritical. Discussion: The written reflection element of educational portfolios needs to be carefully considered because it is clear that many doctors do not find it a helpful exercise. Instead, using the portfolio to record topics covered by a reflective discussion with a facilitator would not only prove more amenable to many doctors but would also allay fears of documentary evidence being used in litigation. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

THE STANDARD SETTING ROLE The founding purpose of the RCGP, when it was established 70 years ago, was to encourage, foster, and maintain the highest possible standards for the emerging specialty of general practice.[1] Despite significant changes in society and professional expectations this mission remains as relevant today as it was in 1952. 3 Royal College of General Practitioners, The future role of remote consultations & patient "triage" General practice COVID-19 recovery. This is the case for most of the Royal Colleges, perhaps particularly the Royal College of General Practitioners (RCGP) because some GPs are more sceptical about institutions than doctors working in other medical specialties. [Extracted from the article]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Understanding the cultural characteristics of healthcare organisations is widely recognised to be an important component of patient safety. A growing number of vulnerable older people are living in care homes but little attention has been paid to safety culture in this sector. In this study, we aimed to adapt the Manchester Patient Safety Framework (MaPSaF), a commonly used tool in the health sector, for use in care homes and then to test its face validity and preliminary feasibility as a tool for developing a better understanding of safety culture in the sector. Methods As part of a wider improvement programme to reduce the prevalence of common safety incidents among residents in 90 care homes in England, we adapted MaPSaF and carried out a multimethod participatory evaluation of its face validity and feasibility for care home staff. Data were collected using participant observation, interviews, documentary analysis and a survey, and were analysed thematically. Results MaPSaF required considerable adaptation in terms of its length, language and content in order for it to be perceived to be acceptable and useful to care home staff. The changes made reflected differences between the health and care home sectors in terms of the local context and wider policy environment, and the expectations, capacity and capabilities of the staff. Based on this preliminary study, the adapted tool, renamed 'Culture is Key', appears to have reasonable face validity and, with adequate facilitation, it is usable by front-line staff and useful in raising their awareness about safety issues. Conclusions 'Culture is Key' is a new tool which appears to have acceptable face validity and feasibility to be used by care home staff to deepen their understanding of the safety culture of their organisations and therefore has potential to contribute to improving care for vulnerable older people. [ABSTRACT FROM AUTHOR]

Better integration of care within the health sector and between health and social care is seen in many countries as an essential way of addressing the enduring problems of dwindling resources, changing demographics and unacceptable variation in quality of care. Current research evidence about the effectiveness of integration efforts supports neither the enthusiasm of those promoting and designing integrated care programmes nor the growing efforts of practitioners attempting to integrate care on the ground. In this paper we present a methodological approach, based on the principles of participatory research, that attempts to address this challenge. Participatory approaches are characterised by a desire to use social science methods to solve practical problems and a commitment on the part of researchers to substantive and sustained collaboration with relevant stakeholders. We describe how we applied an emerging practical model of participatory research, the researcher-in-residence model, to evaluate a large-scale integrated care programme in the UK. We propose that the approach added value to the programme in a number of ways: by engaging stakeholders in using established evidence and with the benefits of rigorously evaluating their work, by providing insights for local stakeholders that they were either not familiar with or had not fully considered in relation to the development and implementation of the programme and by challenging established mindsets and norms. While there is still much to learn about the benefits and challenges of applying participatory approaches in the health sector, we demonstrate how using such approaches have the potential to help practitioners integrate care more effectively in their daily practice and help progress the academic study of integrated care. [ABSTRACT FROM AUTHOR]

Introduction Young adults with diabetes often report dissatisfaction with care and have poor diabetes-related health outcomes. As diabetes prevalence continues to rise, group-based care could provide a sustainable alternative to traditional one-to-one consultations, by engaging young people through life stage-, context- and culturally-sensitive approaches. In this study, we will co-design and evaluate a group-based care model for young adults with diabetes and complex health and social needs in socioeconomically deprived areas. Methods and analysis This participatory study will include three phases. In phase 1, we will carry out a realist review to synthesise the literature on group-based care for young adults with diabetes. This theory-driven understanding will provide the basis for phase 2, where we will draw on experience-based co-design methodologies to develop a new, group-based care model for young adults (aged <25 years, under the care of adult diabetes services). In phase 3, we will use a researcher-in-residence approach to implement and evaluate the co-designed group clinic model and compare with traditional care. We will employ qualitative (observations in clinics, patient and staff interviews and document analysis) and quantitative methods (eg, biological markers, patient enablement instrument and diabetes distress scale), including a cost analysis. Ethics and dissemination National Health Service ethics approval has been granted (reference 17/NI/0019). The project will directly inform service redesign to better meet the needs of young adults with diabetes in socioeconomically deprived areas and may guide a possible cluster-randomised trial, powered to clinical and cost-effectiveness outcomes. Findings from this study may be transferable to other long-term conditions and/or age groups. Project outputs will include briefing statements, summaries and academic papers, tailored for different audiences, including people living with diabetes, clinicians, policy makers and strategic decision makers. [ABSTRACT FROM AUTHOR]

Introduction: The integration of health and social care in England is widely accepted as the answer to fragmentation, financial concerns and system inefficiencies, in the context of growing and ageing populations with increasingly complex needs. Despite an expanding body of literature, there is little evidence yet to suggest that integrated care can achieve the benefits that its advocates claim for it. Researchers have often adopted rationalist and technocratic approaches to evaluation, treating integration as an intervention rather than a process. Results have usually been of limited use to practitioners responsible for health and social care integration. There is, therefore, a need to broaden the evidence base, exploring not only what works but also how integrated care can most successfully be implemented and delivered. For this reason, we are carrying out a formative evaluation of the Waltham Forest and East London Collaborative (WELC) integrated care pioneer programme. Our expectation is that this will add value to the literature by focusing on the processes by which the vision and objectives of integrated care are translated through phases of development, implementation and delivery from a central to a local perspective, and from a strategic to an operational perspective. Methods and analysis: The qualitative and processoriented evaluation uses an innovative participative approach--the Researcher-in-Residence model. The evaluation is underpinned by a critical ontology, an interpretive epistemology and a critical discourse analysis methodology. Data will be generated using interviews, observations and documentary gathering. Ethics and dissemination: Emerging findings will be interpreted and disseminated collaboratively with stakeholders, to enable the research to influence and optimise the effective implementation of integrated care across WELC. Presentations and publications will ensure that learning is shared as widely as possible. The study has received ethical approval from University College London's Research Ethics Committee and has all appropriate NHS governance clearances. [ABSTRACT FROM AUTHOR]

In tune with much international practice, the English National Health Service has been striving to transform health care provision to make it more affordable in the face of rising demand. At the heart of a set of recent radical reforms has been the launch of ‘clinical commissioning’ using the vehicle of local groups of General Practitioners (GPs). This devolves a large portion of the total healthcare budget to these groups. National government policy statements make clear that the expectation is that the groups will ‘transform’ the organisation and provision of health services. In this article, we draw upon interviews, observations and analysis of internal documents to make an assessment of the extent to which clinical leaders have seized the opportunity presented by the creation of these groups to attempt transformative service redesign. [ABSTRACT FROM AUTHOR]

Background A growing body of knowledge exists to guide efforts to improve the organisation and delivery of health care, most of which is based on work carried out in hospitals. It is uncertain how transferable this knowledge is to primary care. Aim To understand the enablers and constraints to implementing a large-scale quality improvement programme in general practice, designed to improve care for people with chronic obstructive pulmonary disease. Design and setting A qualitative study of 189 general practices in a socioeconomically and ethnically-mixed, urban area in east London, UK. Method Twelve semi-structured interviews were conducted with people leading the programme and 17 in-depth interviews with those participating in it. Participants were local health system leaders, clinicians, and managers. A theoretical framework derived from evidencebased guidance for improvement programmes was used to interpret the findings. A complex improvement intervention took place with social and technical elements including training and mentorship, guidance, analytical tools, and data feedback. Results Practice staff wanted to participate in and learn from well-designed collaborative improvement projects. Nevertheless, there were limitations in the capacities and capabilities of the workforce to undertake systematic improvement, significant problems with access to and the quality of data, and tensions between the narrative-based generalist orientation of many primary care clinicians and the quantitative single-disease orientation that has characterised much of the quality improvement movement to date. Conclusion Improvement guidance derived largely from hospital-based studies is, for the most part, applicable to improvement efforts in primary care settings, although large-scale change in general practice presents some particular challenges. These need to be better understood and addressed if improvement initiatives are to be effective. [ABSTRACT FROM AUTHOR]

The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many of the people working in the health sector. This paper presents an emerging model of participation, the Researcher-in-Residence. The model positions the researcher as a core member of a delivery team, actively negotiating a body of expertise which is different from, but complementary to, the expertise of managers and clinicians. Three examples of in-residence models are presented: an anthropologist working as a member of an executive team, operational researchers working in a front-line delivery team, and a Health Services Researcher working across an integrated care organisation. Each of these examples illustrates the contribution that an embedded researcher can make to a service-based team. They also highlight a number of unanswered questions about the model, including the required level of experience of the researcher and their areas of expertise, the institutional facilitators and barriers to embedding the model, and the risk that the independence of an embedded researcher might be compromised. The Researcher-in-Residence model has the potential to engage both academics and practitioners in the promotion of evidence-informed service improvement, but further evaluation is required before the model should be routinely used in practice. [ABSTRACT FROM AUTHOR]

We report an extremely unique and previously unreported case of a pseudoaneurysm arising from an intercostal artery that also gave origin to the artery of Adamkiewicz. Due to the potential risk of losing the artery of Adamkiewicz, a conservative approach was indicated. On short interval follow-up imaging, the pseudoaneurysm and associated hematoma spontaneously resolved with preservation of the intercostal artery. We performed a literature review of the natural course of pseudoaneurysm as well as their occurrence in the intercostal arteries. [ABSTRACT FROM AUTHOR]

Decisions about how to organize and deliver health services are often more complex and seemingly less rational than decisions about what clinical care to provide. The concept of ‘Evidence-Based Management’, or what might more appropriately be termed ‘Evidence-Informed Improvement’, does not seem to have captured the hearts and minds of the people responsible for managing health-care provision. Organizational decision-making is more likely to be influenced by political, ideological and pragmatic factors, and by the personal experience of the decision-makers, than by science. Whilst some people would regard the messiness of management decision-making as inevitable, most would accept that decisions could be improved by making greater use of the established health service research evidence, and through a stronger commitment to developing new evidence. Over the last two or more decades the evidence base created by Health Service Researchers has grown in quantity and in quality and yet much of it remains invisible to the people who most need to use it. This paper explores how the disconnect between the traditional ‘producers’ of research evidence in academia, and the managerial and clinical ‘consumers’ of that evidence, has contributed to the challenge of embedding an evidence-informed approach to service improvement. The advantages of a closer working relationship between academia and health services are outlined and three approaches to evidence creation and utilization are described which attempt to maximize the influence of scientific evidence on managerial practice. [ABSTRACT FROM AUTHOR]

The article describes the things that general practice can learn from the science of improvement to deal with future social and technical changes. Three changes that will have an impact on the ways general practitioners (GP) will operate in the future include the concept of what it means to be a doctor, more informed patients and less willingness to tolerate poor quality care, and new technologies. Areas that GPs will be familiar with through exposure to the social sciences are patient orientation, multidisciplinary and reflective learning.

The author states that there exist deficiencies in the quality of patient care, and highlights the areas in care improvement where health service researchers can make significant contribution. He notes that the researchers need to raise the profile of their work, develop more effective ways of changing practice, make a strong case for a higher level of funding, study crucial environmental elements, and build greater capacity in the field of Improvement Science.

Purpose: The Maturity Matrix is a tool designed in the U.K. to assess family practice organisational development and to stimulate quality improvement. It is practice-led, formative and undertaken by a practice team with the help of trained facilitators. The aim of this study is to assess the Maturity Matrix as a tool and an organisational development measure in European family practice settings. Design/methodology/approach: Using a convenience sample of 153 practices and 11 facilitators based in the U.K., Germany, The Netherlands, Switzerland and Slovenia, feasibility was assessed against six criteria: completion; coverage; distribution; scaling; translation; and missing data. Information sources were responses to evaluation questionnaires by facilitators and completed Maturity Matrix profiles. Findings: All practices taking part completed the Maturity Matrix sessions successfully. The Netherlands, the U.K. and Germany site staff suggested including additional dimensions: interface between primary and secondary care; access; and management of expendable materials. Maturity Matrix scores were normally distributed in each country. Scaling properties, translation and missing data suggested that the following dimensions are most robust across the participating countries: clinical performance audit; prescribing; meetings; and continuing professional development. Practice size did not make a significant difference to the Maturity Matrix profile scores. Originality/value: The study suggests that the Maturity Matrix is a feasible and valuable tool, helping practices to review organisational development as it relates to healthcare quality. Future research should focus on developing dimensions that are generic across European primary care settings. [ABSTRACT FROM AUTHOR]