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How are the social relations of collaboration enacted? In this paper, we address this question by analysing a meeting of researchers at the University of Oxford and the Picker Institute, teams of frontline staff from six National Health Service (NHS) trusts, and a ‘lay panel’, brought together for the US-PEx project.

This article examines the changing nature of the central organization of the NHS and its relations with the field. It is based on a two-year tracer study of regional health authorities (RHAs) as they were reorganized into regional offices (ROs) and became part of the civil service. The research evidence suggests that the centre of the NHS cannot be treated as one organization; the wider Department of Health, NHS Executive HQ and regional offices have distinct identities within it. The analysis therefore looks at relations between these different components of the centre, and between them and the field. The significance of the recent White Paper for the future of regional offices is discussed, with particular emphasis on the tension between centralization and decentralization in performance management, and the opportunity to rebuild strategic co-ordination, which has been difficult to maintain under the internal market.

Pressure to utilize research evidence in decisions about patient care and population health, so-called evidence-based medicine, has swept the health care systems of most industrial countries. In the UK, the attention of policy makers has recently turned from the production of more 'effectiveness information' to the more fundamental challenge of understanding the factors involved in influencing the attitudes and practices of health care professionals. This article seeks to contribute to this process by reporting the findings of an evaluation of a clinical effectiveness initiative established in Wales between 1996-9 (Locock et al . 1999). The study shows that a number of different factors are involved in improving the implementation of effectiveness information, including the strength of the evidence, and the role of peer influence. However it is the interaction of various elements rather than any single factor, which appears to be crucial. These findings are important not only for health but for informing future interventions across other parts of the public sector.

Evidence-based medicine was one of the earliest manifestations of evidence-based policy and practice, and has exercised substantial influence on other policy areas. Based on data from seven empirical studies carried out between 1993 and 1999, this article examines the origins and impact of EBM, and the complexities of implementation which have emerged. Policy makers and EBM enthusiasts alike have frequently taken a somewhat simplistic view of the implementation gap they seek to address. Understanding clinicians’ mixed reactions to the rhetoric of EBM helps explain both why EBM has had as much impact as it has, and why it has sometimes been resisted and rejected. Although other areas of public policy can learn from the experience of EBM, there are distinctive features of health care which set it apart, notably the continued autonomy and dominance of the medical profession and the strong influence of the biomedical science model on what is considered legitimate evidence.

The affiliation for the second author is incomplete. Louise Locock should have the following added to her affiliation: Health Experiences Fellow, NIHR Oxford Biomedical Research Centre.

This article focuses on the diffusion and adoption of innovations in clinical practice. The authors are specifically interested in underresearched questions concerning the latter stages of the creation, diffusion, and adoption of new knowledge, namely: What makes this information credible and therefore utilized? Why do actors decide to use new knowledge? And what is the significance of the social context of which actors are a part?

Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.

Encouraging people to make healthier food choices will make an important contribution to preventing non-communicable diseases. Most groceries purchased by UK households are from supermarkets, potentially making this an important setting where consumers might consider the nutritional quality of foods. While it is possible to purchase healthy food in supermarkets, the retail environment actively promotes the selection of less healthy items. Gaps remain in our understanding about which store based interventions - including providing on-pack nutrition information - can assist shoppers to make healthy food selections. Considerable evidence exists around consumer engagement with nutrition labelling, but there is a paucity of research conducted in real-life contexts. This thesis describes a qualitative study which explored factors which influence decision making at point-of-choice and sought to understand whether and how shoppers use the front of pack nutrition information panel during routine supermarket shopping. The study also investigated whether wearable cameras were useful research tools to understand how shoppers use the front of pack nutrition information panel, compared to a 'Think aloud' method. In this research, participants paid little attention to the front of pack nutrition information as they shopped. Food shopping was characterised as a complex, involved activity with priority given to a range of different issues over health and/or nutrition concerns. Although the front of pack nutrition information panel could offer support to shoppers, this study suggests that its presence is currently overwhelmed by commercially driven factors. Shoppers appear to need specific health or nutrition-related purchasing goals, be sufficiently informed and motivated to spend time attending to the front of pack nutrition information panel. Future interventions should raise awareness of the presence of nutrition information on pack and be clear about how this information can be used in different circumstances to guide consumers towards healthier choices. The study suggests that while data collected via 'Think aloud' or from viewing wearable camera images provides general information about food shopping decisions, eye-tracker technology can provide objective evidence of nutrition information use. Data capture was greatly strengthened by the use of a post-shop interview, where interviews generated specific and important contextual information relating to the use of the front of pack nutrition information panel.