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In April 2013 the local public health function in England was returned from the National Health Service (NHS) to local government, reversing the transfer to the NHS made in 1974 with the abolition of the medical officer of health. Although many in the field had long felt that local government was the appropriate home for public health given its wide-ranging responsibilities for the social determinants of health, the timing was poor. Local government was in the third year of what continued to be an unprecedented ten-year period of austerity imposed by central government with cumulative cuts of the order of 40% for many local authorities. And despite an initial commitment to a ring-fenced public health grant, this grant has been cut each year since 2015–2016 in addition to the wider local authority funding cuts which have had inevitable knock-on effects on the public health function. Crucial public health services such as early years, smoking cessation and sexual health services have all been cut. Despite these cuts the UK government continues to claim a commitment to improving public health and tackling inequalities in health. This study examines the government's discourse on funding local public health services, and the ways in which it has responded to critics through a detailed documentary analysis of key government white papers, ministerial statements and its responses to criticisms, particularly from parliamentary select committees and professional bodies. The paper concludes by considering the implications for effective local public health action in a national regime of austerity. [ABSTRACT FROM AUTHOR]

Since the introduction of the Improving Access to Psychological Therapies (IAPT) programme in NHS England, psychological therapy has gained traction as 'evidence-based' and 'effective' in both clinical and economic terms. In the process, psychotherapeutic care has been reconstituted as highly manualised, standardised, and quantifiable. Drawing on anthropological fieldwork with mental health practitioners, this paper examines some common tensions that practitioners experience in their daily work where psychotherapy is sought within the framework of evidence-based medicine (EBM). For therapists working within IAPT, extensive monitoring and practices of accountability have come to undermine psychotherapeutic efforts to care for patients as 'people'. As a result, many practitioners now feel that they are working in a 'factory of therapy' whereby psychological treatment is recast in the service of outcome measures, and by which critique of the IAPT service, as well as caring relations within it, have been precluded. [ABSTRACT FROM AUTHOR]

The City and Hackney Primary Care Psychotherapy Consultation Service is an innovative, public sector service designed to support GPs in meeting the needs of patients with complex psychological/physical health issues throughout the London Boroughs of Hackney and the City. This paper provides an account of how this new model for the National Health Service (NHS) developed in the context of psychotherapy provision within the NHS, within the national and local context in the UK and gives an overview of some the service's key features and how it differs from other services operating in primary and secondary care. A linked paper, in this journal, explores the reality within which the service functions and describes clinical outcomes, health economic data, the modifications to the original model and prospects for the future. [ABSTRACT FROM PUBLISHER]

Background/purpose: This paper presents the findings of an action research (AR) project to improve a health information system (HIS) at the Operating Theater Department (OTD) of a National Health Service (NHS) hospital in South East England, the UK.Methods: Informed by socio-technical systems (STS) theory, AR was used to design an intervention to enhance an existing patient administration system (PAS) to enable data entries in real time while contributing to the literature. The study analyzed qualitative data collected through interviews, participant observations, and document reviews.Results: The study found that the design of the PAS was unsuitable to the work of the three units of the OTD. Based on the diagnoses and STS theory, the project developed and implemented a successful intervention to enhance the legacy system for data entries in real time.Conclusions: The study demonstrates the value of AR from a socio-technical perspective for improving existing systems in healthcare settings. The steps adopted in this study could be applied to improve similar systems. A follow-up study will be essential to assess the sustainability of the improved system. [ABSTRACT FROM AUTHOR]

Delivering optimal and equitable palliative care is an international challenge. There are few cross-national comparisons examining challenges in expanding palliative care along public health lines. This paper presents a critical review of palliative care in the USA and England, which share similar challenges but have different contexts of healthcare. Beyond some obvious differences in the organisation of palliative care, a set of underlying common issues can be identified. A key tension in both is balancing attention ‘downstream’ in the dying phase, as well as ‘upstream’ earlier in the course of serious illness. In both, the dominant models of palliative care provision have resulted in excellent care towards the end of life for some patients, but there remain major deficiencies in care for the majority. England has a National Strategy for End-of-life care; the US has no equivalent, although a number of influential agencies have published statements. Achieving a public health approach in palliative care requires international consensus on the meaning and target population of palliative care, replacement of prognosis based understandings of entitlement to palliative care with a needs-based approach and development of an evidence base for cost-effective partnerships between providers across the specialist–generalist divide. [ABSTRACT FROM AUTHOR]

This paper explores why leadership, especially senior leadership in British organizations, is persistently nearly always white. The paper contends that beneath the veneer of our apparent commitment to equal opportunities, primitive often unconscious factors operate to ensure that leadership remains white, thus reproducing a racial hierarchy in the workplace. It argues that the barriers to black and minority ethnic people getting appointed to leadership positions in organizations today are largely invisible and are hidden within the psyches of decision makers, the cultures of white organizations, and their combined impact on the confidence of black and minority ethnic staff. [ABSTRACT FROM PUBLISHER]

Whilst an earlier paper (Part 1) in this journal describes the historical, political and economic drivers behind the creation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), this paper (Part 2) focuses on exploring the context within which the service functions. The paper provides an overview of its operational model and is organised into 10 sections. The first section outlines the service's clinical practice, whilst the second addresses the value of GP consultations as a core part of the PCPCS's provision. The third section addresses how the service, as departure from a more ‘pure’ psychoanalytic tradition of providing longer-term therapy, has managed its provision of brief treatments. There is a description of how the service manages its team of multi-disciplinary clinicians and their work in a variety of micro-cultures, conveying some of the challenges faced by the service and the team since its inception. Thereafter, the quantitative and qualitative evidence for the service's clinical and cost effectiveness is assessed, including outcome results and findings from a health economic evaluation. To illustrate some of the service's work in practice, some disguised clinical vignettes are presented. The paper also summarises the service's recent clinical innovations, as well as its contribution to the field of research, audit and training. Finally, the way forward for the service is considered in the context of current and emerging trends in psychological provision in primary care. [ABSTRACT FROM PUBLISHER]

Background: The concept of recovery is contested throughout the existing literature and in mental health services. Little research exists that gives voice to service user perspectives of recovery. Aim: This paper explores how service users in two recovery oriented services run by the National Health Service in North West England talked about recovery and what it meant to them. Method: 14 service users accessing these services took part in semi-structured qualitative interviews focusing on the concept of recovery. Data were analysed using an interpretive phenomenological analysis approach. Results: Service users talked about recovery as a dynamic, day to day process as well as an outcome; specifically related to being discharged from inpatient settings. A number of factors including relationships and medication were cited to have the potential to make or break recovery. Conclusions: The study highlights the continued dominance of the biomedical model in mental health services. Service users appear to have internalised staff and services’ understanding of recovery perhaps unsurprisingly given the power differential in these relationships. Implications for clinical practice are explored. [ABSTRACT FROM AUTHOR]

Never before have public sector jobs been so threatened. Fear and anxiety have shifted their focus, from performance to survival. With reference to immediately contemporary works on the NHS in particular, such as Mandelstam (2011) and Leys and Player (2011), the paper establishes the factual validity of the crisis. The authors conducted a series of workshops for public sector staff to enable them to explore their reactions to the current situation. It is possible to identify increasing levels of denial and other forms of resistance to change similar to those first identified by Menzies' (1959). Drawing on the work of Bion (cited Obholzer & Roberts, 1994) the paper considers the dangers of a retreat to the paranoid schizoid position, and identifies a theoretical clue in Halton (2004) for turning the trauma of change into a creative opportunity. Art has access to emotional, spiritual and creative facets of the human mind that science cannot explore. Klein's (1975) consideration of the infantile and regressive aspect of art is acknowledged. The paper then considers what is revealed by a study of specific works of art which were presented in the workshops; including paintings by Bosch, Rousseau, Breughel and Goya. The work of Zagier-Roberts (1998) and Winnicott (1971) is called upon to endorse the usefulness of such a playful collage of responses. Art can be used to help people move through Kubler Ross' stages of bereavement (1997); not to acceptance but out of the paranoid schizoid position into the depressive position (Klein 1975). Revisiting the work of Halton (2004) and the concept of evolutionary creativity, a move on from the depressive position can begin. Collective validation can be affirmed through a rebooting of the essential public sector values while a radical turning away from organisational priorities, to face the service user, provides a more far reaching optimism than any envisaged by an essentially limited demand for modernisation. In conclusion the paper considers the recent contributions of Dienst (2011) and Dumenil and Levy (2011) to advocate tactical resistance to the denigration of the public sphere. [ABSTRACT FROM PUBLISHER]

What prevents the delivery of effective, high quality and safe health care in the National Health Service (NHS) in England? This paper presents 760 challenges which 330 NHS staff reported as preventing the delivery of effective, high quality and safe care. Some problems have been known for over 25 years (staff shortages, finance and patient complexity) but other challenges raise questions about the commitment of the NHS to patient and staff safety. For example, Organisational Culture leading to ‘stifling bureaucracy’, ‘odds stacked against smooth […] working’ and Workload resulting in ‘firefighting daily’ and ‘perpetual crisis mode’. The role of Human Factors/Ergonomics professional input (engagement with safety scientists) is discussed in the context of success stories and examples of Human Factors Integration from other safety critical industries (Defence, Nuclear and Rail). Practitioner Summary:760 challenges to the quality, effectiveness and safety of health care were identified at Human Factors/Ergonomics taster workshops in England. These are used to challenge health care providers to think about a Human Factors Integration (HFI systems) approach for safety, well-being and performance for all people involved in providing and receiving health care. [ABSTRACT FROM PUBLISHER]

Different versions of choice are at work in England's National Health Service. A hard version of choice associated with provider competition (and patient exit) appears to be giving way to a 'softer' concept of 'personalization', emphasizing choice and voice at the micro level, but also drawing on solidaristic themes. As personalization becomes increasingly central to health reform, it is important to interpret the ways in which a personalization narrative is being used. It is also necessary to trace its ambivalent framing of National Health Service patients, staff and structures. This paper uses textual analysis to explore how personalization has been positioned in ministerial speeches and health policy documents. It finds that personalization is located in a discourse of organizational decline and disruption, emphasizing the need for patient exit and voice as recuperative mechanisms, but also one of consolidation, trust and equity, emphasizing loyalty to shared welfare services. Hirschman makes clear that an interplay between exit, voice and loyalty is to be expected. However, there is an ambivalence in their relationship which is being ignored by health policy-makers. Frontline staff and service users are left to negotiate an agenda which positions them as both partners and adversaries. [ABSTRACT FROM AUTHOR]

A number of studies have previously been published on the benefits of GP appraisal. Ours is the first study that compares the views of doctors registered before and after the introduction of appraisals on various core elements of the appraisal process. This study aimed to explore potential differences, between GPs qualifying before and those after the introduction of NHS appraisals, on the utility of the appraisal process. Additionally, to discover the perceived impact of appraisals on interaction with colleagues and patients. Suffolk appraisers were recruited to distribute a paper questionnaire, in two sections, for each appraisal undertaken over a 12-month period. The first part of the questionnaire related to that specific appraisal. The second part, seven questions using Likert scales and free-text comments, asked about the appraisal process in general. The feedback from the second part forms the data for this study. Overall, doctors tended to agree that appraisals had a beneficial impact in the core areas investigated. However, there was a significant difference between generations: those registered before 1998 were less likely to find NHS appraisals beneficial. Both groups reported that preparation took up too much time. Opinions regarding the impact of appraisals on interaction were evenly divided amongst appraisees, with the older cohort more likely to report negatively. There is a generational difference amongst GP in the perceived utility of NHS appraisal. Current plans to redesign the process to make appraisals less onerous will be welcomed by both groups. [ABSTRACT FROM AUTHOR]

This paper describes a preliminary investigation on the effectiveness of Dynamic Interpersonal Therapy (DIT). The research was undertaken in an inner London primary care psychological therapies service. Outcome data on the symptoms of depression [Patient Health Questionnaire-9 (PHQ-9)] and anxiety [Generalised Anxiety Disorder-7 (GAD-7)] were collected from service-users (n = 24) at the first and last episodes of treatment. There were statistically significant reductions in depression (PHQ-9) and anxiety (GAD-7) associated with DIT, with medium and large effect sizes, respectively. Overall, 75% of patients showed an improvement on the PHQ-9 and GAD-7 following DIT. When this was calculated as statistically reliable change, the improvements reduced to 42% for anxiety and 25% for depression. As this study was uncontrolled, the significance cannot be reliably attributed to DIT. Future research may aim to investigate DIT's effectiveness in different settings with a larger sample size, using appropriate comparison groups under controlled conditions. [ABSTRACT FROM PUBLISHER]

Background Health literacy is important because of the high proportion of the population with skills below those needed to become and stay healthy, and the resultant negative impact on people's lives. A recent study in England has shown that, as is true in other industrialized nations, a significant proportion of people (43–61%) have literacy and numeracy skills below those needed to fully understand and use health materials. This paper describes a project designed to build on these findings with key stakeholders to develop an action plan to address a mismatch between population skills and the health system complexity. Method The multi-stage project involved an initial meeting of stakeholders that allowed participants to share knowledge and experience, and make suggestions for change. Subsequent web-based surveys enabled widening of the stakeholder group, identification of further potential actions, and participant rating of the impact of the suggested actions on this mismatch. Next, a meeting enabled the group to identify priorities for change that would be feasible and cost-effective. Results Forty-one participants were recruited from a range of patient, health, lifelong learning, civil service, and industry perspectives. Suggested topics for action fell into four areas; improving health services, building health literacy skills in the population and workforce, recognizing the importance of public information developed outside the health arena, and funding for health literacy research and development. Following consideration of likely cost, impact, and feasibility, five suggested areas were prioritized for action, three involving improvements in the health service, and two involving the development of public health literacy skills. The importance of inter-sectoral approaches to this complex issue was identified. Discussion This project recruited key stakeholders with a wide range of relevant expertise and perspectives. It resulted in a clear, coherent action plan to address the population skills: health system complexity mismatch. Next steps include implementation, evaluation, and widening to other areas of life important to public health and well-being such as public safety messages and social care. [ABSTRACT FROM AUTHOR]

Objective:This study aimed to explore health visitors’ (HVs) experiences of the assessment of women with psychological distress and mental health problems across the perinatal period in clinical practice.Background:In international contexts, there is now a firm policy remit for the assessment of psychological and mental health disorder across the perinatal period. Women are in regular contact with health professionals across this time and consultations intuitively create an ideal and appropriate context in which to assess women’s psychological health. National reports and academic literature highlight that to prevent the escalation of perinatal mental illness, significant change is needed to support health professionals in detecting, discussing and dealing with mental illnesses.Methods:In a qualitative aspect of a larger mixed-method study, data were collected from two Focus Group Discussions with HVs pre and post a training session related to assessing and managing perinatal mental health problems in practice. For the purposes of this paper, the data were explicitly examined for references to recognition and assessment.Results:Four themes emerged from the data: recognising the problem; questioning and identification; so what do I do now; the importance of support to promote effective identification and assessment.Conclusion:Findings elucidate the complexities that practitioners face in assessing women’s psychological health in real world settings. HVs’ experiences highlight that the implementation of measures into practice needs to be workable and accompanied by contemporary and appropriately contextualised knowledge, adequate service provision and clear referral pathways to ensure effective assessment of women’s psychological health. [ABSTRACT FROM PUBLISHER]

Scientific-bureaucratic medicine (SBM) has been the dominant discourse on evidence-based medicine in the English National Health System (NHS). It has being claimed that SBM has led to new forms of medical professionalism with an emphasis on organisational values and the control of autonomy. This paper explores the medical professions' response to SBM, where SBM is manifested in the form of National Institute of Health and Clinical Excellence (NICE) guidelines. Seventy-four face-to-face informal interviews were carried out with clinicians and managers between 2007 and 2009. Three major themes emerged from the analysis each of which was linked to doctors' receptiveness to NICE guidelines implementation. The first emphasised organisational values, which accounted for conditional acceptance of NICE guidelines. The second was proactive professionalism or entrepreneurial professionalism, which was linked to the rejection of NICE guidelines and the emergence of alternative forms of introducing new ideas for the expansion of their clinical practice. The third was related to the prominence of clinical autonomy linked with doctors' resistance to the use of NICE guidelines. It is argued that this evidence does not reflect a significant emergence of new forms of professionalism but the development of multiple occupational identities. [ABSTRACT FROM AUTHOR]

This paper draws parallels between the market trend in the English NHS and Polanyi's (1957) The Great Transformation: The political and economic origins of our time, Beacon Press: Boston (originally published in 1944 in the United States as The Great Transformation, Rinehart: and Co: New York, and in 1945 in England as Origins of our time, Gollancz: London) account of how the rise of markets provokes a self-protective counter-reaction that tries to re-embed economic relations in social relations. We report findings from a qualitative study of NHS contracting, which examines the recent move to harder-edged contracts with greater use of financial penalties and incentives. In practice, use of these techniques tended to be confined to nationally-mandated sections of the contract rather than emerging from local bilateral agreements, and when things went wrong the parties relied more on cooperative behaviour than on the provisions of the contract to find solutions. Making the current contracting system work depended more on existing relational networks than on the incentive structures created by recent 'marketisation' initiatives, but the inability of the market to evolve as expected has encouraged policy makers to publish plans for further radical reforms. [ABSTRACT FROM AUTHOR]

The authors describe the incremental approach to the marketisation of the English National Health Service (NHS) since the introduction of an 'internal market' in 1990 until the 2010 White Paper, 'Equity and Excellence: Liberating the NHS', and the subsequent Health and Social Care Bill published in January 2011. The introduction of a competitive market for a universal, tax-financed health system requires fundamental changes in regulation in order that market bureaucracy can be substituted for direct management. The components of reform are insufficiently captured by the framework of hierarchies and networks in new public management theories of decentralisation. [ABSTRACT FROM AUTHOR]

In this paper I will attempt to describe the treatment of a seriously ill patient in a National Health Service (NHS) clinic who suffered from recurrent depressive disorder with co-morbidity, repeated breakdowns and was at risk of suicide. The purpose of writing a clinical case study is to illustrate the vital importance of a psychoanalytically-informed approach in the treatment of a very ill patient in the public sector. At a time when there is a decrease in the provision of long-term psychoanalytic psychotherapy my aim is to illustrate its value in the understanding and treatment of complex disorders, a perspective that seems to be under constant threat from internal and external pressures and at risk of being sidelined as a non-evidence-based form of treatment. I will try to describe the different stages in the treatment; from referral through to the beginning of treatment, its interruption, the patient's breakdown and admission, and finally his return to treatment upon discharge. The ending will be discussed with a view to highlighting some of the patient's internal movements enabled by the work undertaken. [ABSTRACT FROM AUTHOR]

This article examines how deaths related to mental health in England and Wales are investigated and the extent to which lessons are learned in their aftermath. It uses two concepts from academic literature to discuss organisational responses to these deaths: organisational learning, and organised irresponsibility. Organisational learning stresses the importance of learning lessons from data; in contrast, Beck's concept of organised irresponsibility states that organisational lesson learning is impeded by the fragmented and risk-averse nature of public institutions. The article considers 210 organisational responses to Reports to Prevent Future Deaths (PFDs) issued by Coroners. PFDs are sent to any organisation Coroners believe could act to prevent future deaths. The article identifies three findings: Firstly, organisations tend to produce generic responses rather than addressing specific issues raised by Coroners. Second, organisations tend to cite existing policies as responses to Coroners despite those policies not preventing specific deaths. Third, institutions seek to displace blame onto other organisations in attempting to avoid accepting responsibility for the death. The article adds to the canon of knowledge on deaths in healthcare, and in the care of the state by identifying significant structural weaknesses that impede organisational lesson learning about preventable deaths. [ABSTRACT FROM AUTHOR]

Access to in vitro fertilisation (IVF) funding in England is limited by a range of local criteria set out historically by Clinical Commissioning Groups (CCGs) (now superseded by Integrated Care Boards (ICBs)). Many of these criteria discriminate on the grounds of sexual orientation, relationship status and existing family structure. Contrary to increasing rates of IVF treatment across the UK, NHS funding for IVF treatment has decreased, in some cases rapidly, across most areas of England. This article reviews the eligibility criteria previously developed by CCGs and critically examines three major discrepancies in entitlement to funding: (i) the postcode lottery; (ii) restrictions placed upon lesbians and single women; and (iii) existing family structures as less deserving of funding. Inconsistencies in IVF funding are framed within broader discussions of discrimination and inequality within fertility funding. Recommendations for social and political change are made, alongside areas for future research engagement. [ABSTRACT FROM AUTHOR]

Social Work Teaching Partnerships were initiated by the UK government in 2015. The purpose was to improve the quality of social work education and training. In the East Midlands, four Local Authorities (Derbyshire, Derby City, Nottinghamshire and Nottingham City) joined with other local organisations to form the "D2N2" Social Work Teaching Partnership (the D2N2 acronym representing the two Derbyshire and two Nottinghamshire local authorities). The Partnership was formally recognised as a Teaching Partnership in 2016. As part of our commitment to improving social work education and training, we identified a need to develop our practice education (field education) further, by developing a revised and improved placement quality assurance system that replaced the Quality Assurance in Practice Learning (QAPL) system, which was not felt to be fit for purpose. This work formed part of a wider Placement Learning System (PLS) and Practice Development Programme (PDP), which were developed in conjunction with the Universities and employer organisations. The PLS enhanced the voice of the student whilst at the same time allowing us to gather a significant amount of data about the quality of placements; and the PDP allowed us to develop our practice educator cohort. This article explores these developments. [ABSTRACT FROM AUTHOR]

Evidence suggests that despite the popularity and influence of key health equity concepts, they often fail to shift the thinking and actions of health workforces towards the social and structural determinants of health inequalities. These findings tend to be attributed to institutional constraints, along with the role of influential discourses which promote a focus on individuals and behaviours. However, questions have also been raised about the clarity and utility of the concepts themselves, and the extent to which the language they use works (or indeed fails to work) in reorienting thinking and action. The purpose of this study was to explore how partners in an applied health research collaboration in England interpreted the popular 'upstream-downstream' story, and what it means to work 'upstream' to reduce health inequalities. Where participants were not familiar with its academic or technical usage, the story was taken to be a metaphor for prevention generally, or it prompted a root cause analysis of the more discrete ways in which inequalities were encountered in participants' research or work. Even in instances where participants did hold more socio-political perspectives, these were often not evoked by the metaphor itself. Two of the 18 participants were unable to equate the metaphor with particular actions or ways of working, while others found it to be a poor fit with how they understood inequalities. The study findings illustrate and explain the challenges that arise when technical metaphors from the health equity literature are opened-up to interpretation by wider audiences. [ABSTRACT FROM AUTHOR]

Undergoing an amputation is a life-altering experience that can involve a protracted and intensive period of care from a range of healthcare professionals. Amputation care within the NHS has historically been criticised. Here we seek to understand how patients are experiencing care by exploring their stories and identifying features of both high- and low-quality care. We analysed patient stories posted on the patient feedback site Care Opinion during the period 2018–2020 to examine how amputee patients (and their families) experience NHS care. Using thematic analysis, we identified four key themes. We found that patients' stories of undergoing an amputation as posted on Care Opinion give overwhelmingly positive feedback on their experiences. Patients report feeling well-supported by empathetic staff, and that the outcomes, in terms of quality of life and restoration of mobility, are beneficial. Time was a common feature within the posts we examined and negative experiences of care often related to untimeliness in a variety of ways. Care Opinion provides a useful and accessible resource for understanding how patients experience amputation care; analysis of stories posted there provides preliminary ideas of the features of "good care" from a patient-centred perspective. Patients undergoing amputations view professionalism of staff as important for good care. Timeliness is important to patients in seeing care in positive terms, ensuring patients are supported in their care during and after amputation in a timely manner is therefore important for achieving good rehabilitation care. Rehabilitation and related services supporting patients who have undergone amputations could usefully patient feedback sites as a means for further understanding the experiences of their patients and for improving services where necessary. [ABSTRACT FROM AUTHOR]

Busy health-care professionals have a duty to apply the evidence base to practice and decision-making. Health-care knowledge and library specialists have the skills to provide efficient and effective evidence searches. To identify the advantages and cost benefits associated with knowledge and library specialists undertaking evidence searches on behalf of health-care professionals, evidence from a literature review was combined with impact case studies of evidence searches in NHS Knowledge and Library Services, identifying time savings and cost benefits. The cost-effectiveness ratio for knowledge specialists delivering evidence searching services was identified as 1:3.85 with the current net benefit to the NHS in England estimated at £37 million (42 million U.S. dollars). A range of additional benefits are also generated through using knowledge and library specialists. Greater investment in these specialists would ensure accelerated access to better quality evidence and maximum benefit across health-care systems. [ABSTRACT FROM AUTHOR]

Contracting in the public sector is designed to enhance the accountability of service providers to their funders. The idea is that quality is improved by the use of service specifications, monitoring of performance and imposition of contractual sanctions. Socio-legal and economic theories of contract indicate that it will be difficult to make and enforce contracts to achieve this. The results of a study of National Health Services contracting in England and Wales are reported. We conclude that contracts alone are not sufficient to improve accountability – collibration of various regulatory measures (including more hierarchical mechanisms such as performance targets) is required. [ABSTRACT FROM PUBLISHER]

Single-sided deafness presents communication challenges for adults. There are a range of care options, including CROS hearing aids, available but little is known about patient preferences for these interventions. The objective of this study was to understand the viewpoints of patients making decisions about audiological interventions they use. A constructivist worldview using thematic analysis to undertake a constant comparative analysis of 8 semi-structured interviews. Participants were recruited from Portsmouth Hospitals University NHS Trust audiology service in England. The results of the study describe ongoing iterative judgements being made by participants, informed by their access to information, effectiveness of audiological interventions, stigma, barriers to accessing care, and constant cost-benefit analyses being made. The key factors involved in decision-making by individuals with Single-sided deafness (SSD) are discussed. This study represents the first in-depth exploration of the individual's lifeworld related to which factors influence use of different audiological interventions by individuals with SSD. It highlights the complex and ongoing nature of how decisions are made by these individuals and identifies the need for greater information provision by clinicians, such as through use of a decision aid tool. [ABSTRACT FROM AUTHOR]

Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed. Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who "push" these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice. This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised. Redesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making. Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty. Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice. Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre. [ABSTRACT FROM AUTHOR]

The DESCANT (Dementia Early Stage Cognitive Aids New Trial) intervention provided a personalised care package designed to improve the cognitive abilities, function and well-being of people with early-stage dementia and their carers, by providing a range of memory aids, together with appropriate training and support. This sub-study aimed to assess implementation and identify contextual factors potentially associated with participant outcomes. A mixed-methods approach was adopted alongside the pragmatic randomised trial. Data were obtained from intervention records and interviews with five dementia support practitioners across seven National Health Service Trusts in England and Wales. A reporting framework was constructed from available literature and data assessed by descriptive statistics and thematic analysis. Participation and engagement was high with 126 out of 128 participants completing the intervention with packages tailored to individual participants. Misplacing items and poor orientation to date and time were common areas of need. Memory aids frequently supplied included orientation clocks (91%), whiteboards (60%), calendars (43%) and notebooks (32%), plus bespoke items. Intervention duration and timing were broadly consistent with expectations. Variation reflected participants' needs, circumstances and preferences. Qualitative findings suggested a potentially positive impact on the well-being of people with dementia and their carers. Issues associated with successful roll-out of the intervention are explored in the discussion. Successful implementation increased confidence in future findings of the randomised trial. Depending on these, DESCANT may prove a scalable intervention with potential to improve the function and quality of life of people with dementia and their carers. [ABSTRACT FROM AUTHOR]

Objective We know little about how goal setting is actually delivered in routine practice. The National Health Service Diabetes Prevention Programme (NHS-DPP) is a behavioural intervention aiming to prevent progression to Type 2 diabetes in those at risk. It has been delivered across England by four commercial providers. This study aimed to establish whether goal setting in the NHS-DPP was delivered in line with the current evidence base. Design: Observational study and document review. One-hundred-and-eighteen NHS-DPP sessions with 419 people were observed at eight sites (two sites per provider). Main outcome measures: Multiple characteristics of goal setting were reliably coded from each providers' programme plans (intended goal setting) and from audio-recorded NHS-DPP sessions (actual goal setting). Results: Providers intended to deliver goal setting in 88.3% of sessions, though goal setting was delivered in only 52.5% of sessions. During delivery, the observed goals set across providers were generally specific (62.5%), set privately (53.1%), with goal difficulty rarely mentioned (3.1%). Conclusions: Goal setting in the NHS-DPP is being under-delivered, and not in line with the evidence base for promoting behavioural change. Goal setting in national behaviour change programmes should be optimised and training provided specifically for goal setting. [ABSTRACT FROM AUTHOR]

A new diagnosis of Complex Post-traumatic Stress Disorder, CPTSD, is included in ICD-11 which was adopted in May 2019 by the World Health Organisation, WHO. In addition to the symptoms of PTSD, CPTSD includes emotional dysregulation, negative self-concept, and disturbances in relationships. It may be a helpful diagnosis for trauma survivors with experiences of human mistreatment such as torture and abuse. This study explores the views of patients in the community on psychotherapy for the diagnosis of CPTSD, taking a qualitative, participatory approach. Twenty-four former patients from an NHS secondary mental health service in London interviewed each other about their treatment. Participants also collaborated in data analysis. All had a diagnosis of PTSD, with additional symptoms of CPTSD identified at assessment. The key factor in recovery was rebuilding relationships, beginning with the therapist. Groupwork was helpful in promoting relationships with others, as it may result in shame reduction. Involvement in the wider community through peer support groups was also valuable. The rebuilding of relationships based on trust was an active mechanism of change and recovery from CPTSD. Participants felt that sufficient time, at least one year of psychotherapy with weekly sessions, was needed. [ABSTRACT FROM AUTHOR]

The concern of this study is a blindness to risk assessment of mental health and safety issues for children and young people by Child and Adolescent Mental Health Services (CAMHS) teams when they are insufficiently emotionally contained. The need for social worker membership of CAMHS teams is suggested but not developed, as the focus is unconscious processes that debilitate required thinking by CAMHS about risk. A case example allows discussion of various ways in which primitive anxieties within CAMHS teams lead to paucity in thinking about risks. Located at the beginning of life, primitive anxieties are contained through nourishment. It is suggested without nourishment, and its consequent provision of a containing boundary for these anxieties, teams can dangerously dysfunction in primitive infantile states. These persecutory mental states are traced as the cause of a depleted thinking capacity, which may inadvertently place patients at increased risk through errors and oversights. [ABSTRACT FROM AUTHOR]

Background:In 2019 the Association of Visually Impaired Chartered Physiotherapists, originally the Association of Blind Certificated Masseurs, celebrated the centenary of its formation and becoming the first ever Specific Interest Group admitted to the Incorporated Society of Trained Masseuses which, later in the 20th century, became the Chartered Society of Physiotherapy. These landmarks motivated the author to research for this chronological, descriptive, narrative review of the history of blind physiotherapy and its contribution to physiotherapy in the United Kingdom. Purpose:The early training and practice of massage by blind practitioners, the organizational milestones in mainstream and blind physiotherapy and the inter-relationship between the two is considered. Key developments, challenges, innovations and opportunities throughout the history are reviewed including the impact of World War 1 and contribution of blind physiotherapy to the profession. Conclusion:Significant changes in physiotherapy educational and training arrangements for blind students and changes in physiotherapy practice generally over the last four decades engender serious questions about whether blind physiotherapy will still "belong", despite the increasing aspiration within society toward acceptance of diversity and inclusion. The author challenges the profession about whether it will facilitate blind physiotherapy to continue making its valuable contribution and be included. Will it still "belong?" [ABSTRACT FROM AUTHOR]

Objective: To understand the experience of people who seek help for subjective cognitive concern and memory loss, including people not referred for further assessment. To understand the patients' perspective of the medical process of receiving a cognitive assessment. This work is situated within the context of policy priorities for dementia diagnosis. Methods: Participants with and without dementia were recruited through NHS trusts and community organisations in four regional areas in England. Data were collected using longitudinal qualitative interviews. Transcript data were thematically analysed. Results: Sample of 41 people (mean 75 years, 25 dementia diagnoses). Interpretative thematic analyses focused on the presence or absence of trust in relational experiences. There were three transition points where trust could be specifically developed or undermined: (1) deciding to seek help; (2) healthcare practitioners' response to help-seeking; (3) process and outcome of assessment. Triggers for help-seeking for subjective cognitive concern were being prompted by family and knowing a relative with dementia. When participants perceived healthcare practitioners' behaviour as dismissive, they had less trust in the outcome of the healthcare encounter. Misunderstandings and absence of trust in assessment processes led to participants stating they did not fully agree with the outcomes of the assessment. Conclusions: Healthcare practitioners have an important role in supporting people with subjective cognitive concern ensuring patients have trust in assessment outcomes. Where the validity of the assessment process is seen as ambiguous, people can be left dealing with uncertainty, rather than being clear about ways they can manage their condition, situation or status. [ABSTRACT FROM AUTHOR]

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation. Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping. Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators. Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered. [ABSTRACT FROM AUTHOR]

The impact of working as art therapists in the NHS during protracted change processes, with people with learning disabilities (LD), was investigated in a qualitative heuristic doctoral study (Ashby, 2018), which considered concerns about emotional exhaustion and reduced efficacy, symptoms of burnout (Maslach, 1982), as a result of occupational stress. The researcher's own data was examined, and 15 art therapists employed by NHS Trusts across England were interviewed. This article explores how the research was conducted, its findings related to LD services in the NHS and wider employment issues, and addresses how the findings are relevant to all art therapists. Most burnout studies are quantitative and consider workplace sources of occupational stress, but this qualitative research importantly revealed how crucial personal sources of support and stress were in terms of aiding or reducing clinicians' capacities to cope. There was evidence of job satisfaction, resilience, and personal growth developed over years of practice, and high levels of stress resulted in symptoms of burnout in some participants, but recovery was shown to be possible. Plain-language summary Research into the impact of working as an art therapist in learning disability (LD) services in the NHS in England during long periods of change processes found sources of stress and of job satisfaction (Ashby, 2018). The doctoral research was qualitative, using heuristic methodology as the researcher had experience of the issues investigated, and 15 art therapists were interviewed. This article discusses the relevant literature, the way the research was done, and findings of the research; it applies the knowledge gained to the situations many art therapists experience in their practice with different organisations and work environments. The impact on art therapists was investigated as both positive and negative aspects of their working lives were evident, and sources of job satisfaction and of occupational stress were experienced, including burnout symptoms of emotional exhaustion and reduced capacity to work, though not depersonalisation (Maslach, 1982). Organisational sources of satisfaction and stress within NHS LD services were identified, and employment issues for art therapists became apparent in relation to job insecurity, within the depressed employment market. This qualitative research found that personal sources of support or stress could result in art therapists being able or unable to manage coping with occupational stress if multiple sources of stress were present. Burnout symptoms of emotional exhaustion and a reduced capacity to manage their workload resulted from these situations for some participants, however, those affected were able to recover when they addressed the occupational stress that had become too much for them; no participants avoided contact with service users. [ABSTRACT FROM AUTHOR]

Background: The literature surrounding patient feedback is limited, despite government policy integrating patient feedback into how the care quality of the National Health Service (NHS) is assessed. The aim of the study is to examine the detailed contextualised accounts of patient feedback within forensic and non-forensic settings through qualitative and quantitative analyses. Method: Responses which reflected positive or negative/neutral overall feedback were analysed using Chi-Square tests on a total of 906 patient responses in a large NHS Trust in England. Conventional content analysis was conducted on 222 patient free-text comments, deriving codes and distributing these into categories. Findings: Forensic patients were more likely to give negative feedback on mental healthcare services than non-forensic patients. The service's level of security-impacted patient's willingness to engage with giving feedback. The qualitative analysis provided further insight into these differences by identifying themes in the data. Conclusion: The findings of the present study highlight the challenges faced by staff and volunteers when collecting patient feedback, exploring important differences between services. The study makes recommendations to practice-based interventions to reduce the consequence of these challenges and explores recommendations for future research. [ABSTRACT FROM AUTHOR]

Objectives: To compare the 3-year cost in the NHS in England of continued aflibercept injections with that of switching to a single fluocinolone acetonide (FAc) intravitreal implant in phakic patients with chronic diabetic macular edema (DME); that is, DME that persists or recurs despite treatment. Methods: A cost analysis model was developed. This accounts for the overall direct cost of treatment in phakic eyes, including the costs of the drugs, administration, monitoring, additional interventions required, and adverse event management. Results: This model shows cost savings for patients with a phakic lens when they are switched to FAc following initial aflibercept monotherapy. Using NHS list prices, the total treatment cost over a 3-year period per phakic eye is £15,413.23 with continued aflibercept monotherapy and £14,485.06 with a switch to FAc - resulting in a cost saving with FAc of £928.17 per eye over a 3-year period. Conclusions: This cost analysis showed that switching patients with an initial suboptimal response from aflibercept to FAc was associated with a cost advantage compared with continued aflibercept injections. With increasing demand for intravitreal therapies, the true benefit of treatment with FAc may be its potential as a suitable and effective option to increase clinic capacity. [ABSTRACT FROM AUTHOR]

In the United Kingdom, speech and language therapists (SLTs) and Stroke Association communication support coordinators (CSCs) are both employed to provide services for people with communication difficulties following stroke. There is very little literature of this type of collaborative working. This research is unique because it explores collaborative working between SLTs who are employed by the National Health Service and CSCs who are employed by the Stroke Association. Five CSCs and seven SLTs from the East of England participated in a series of in-depth interviews. Data were analysed using thematic analysis informed by an interpretative phenomenological approach. The analysis suggested complex negotiation processes occur at a number of different levels. These levels include negotiation of individual relationships between SLTs and CSCs, negotiating the particular challenges involved in working across organisations and professions, and the need for both roles to negotiate and promote the value of their services at a societal level. The findings of this research are discussed in relation to existing theories and research within the field of collaborative working. Clinical applications are suggested for collaborative working within communication services. We propose that our findings may have relevance to other individuals and organisations delivering services collaboratively. [ABSTRACT FROM AUTHOR]

Purpose: Hip osteoarthritis (OA) is a chronic musculoskeletal condition affecting 2.5 million people in England. There is limited evidence on practice in the United Kingdom (UK) by physiotherapists in the public sector. A snapshot survey was conducted in a limited time period to inform standard care in a trial funding application. Methods: An online survey was circulated using Twitter. Thirteen Tweets linking to the survey were posted over 6 days to gain a snapshot view of physiotherapy practice within the public sector in the UK. Results: Sixty-two physiotherapists from 25 counties in the UK and Wales responded. The median waiting time from referral to physiotherapy treatment was 5 weeks and patients were seen a median of 3 times. The median total number of hours treated was 2 hours, and the median duration time for treatment was 8 weeks. All respondents used strengthening exercises, 73% stretches, 50% cardiovascular exercise, 73% balance exercises and 26% proprioceptive exercises. Thirty-nine percent of respondents use both strengthening and cardiovascular exercises, and provide an education leaflet, as contained within National Institute for Health and Clinical Excellence (NICE) guidance. Conclusions: This snapshot suggests that physiotherapeutic management varies widely across the UK. [ABSTRACT FROM AUTHOR]

Purpose:To establish whether different processes underpin changes in disability in people with neck pain who underwent two types of active physiotherapy intervention. Materials and methods:This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability. Results:In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant β value in the final model. Conclusions:Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach.Implications for rehabilitationCertain cognitive factors are known to be related to levels of disability in patients with chronic neck painSpecifically targeting these factors results in more patients making a clinically meaningful reduction in disabilityDifferent processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner.Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain. [ABSTRACT FROM PUBLISHER]

This article discusses the impact of a 'life-story film' - co-created with a person with dementia - on NHS staff's perceptions of the person, and by implication, their wider perceptions of people living with dementia. The study used an innovative research method, the visual matrix, to encourage hidden images, feelings and ideas to emerge. A complex, multi-layered experience emerged through rich metaphorical language, encompassing both personal and broader sociocultural understanding of dementia. An unexpected outcome was the quasitherapeutic effect of the visual matrix on staff. The study suggests that the visual matrix may have potential to be adapted as a training tool in dementia care and that the fluid, associative and non-linear qualities of the visual matrix may prove an effective method for gathering the views of people with dementia, whose authentic voices are under-represented and difficult to gather using traditional research methods. [ABSTRACT FROM AUTHOR]

Background: Since 1990, health policy in England has stressed the importance of user involvement in shaping and delivering services. Aims: To explore mental health service user-led organisations (ULOs) in England, as they interact with decision-makers to bring about change desired by them with a focus on institutional norms behaviour and specialised knowledge impacting service users' relationships with services. Method: An ethnography of five ULOs in two provider organisations (NHS Trusts) including observing their meetings and interactions with decision-makers, conducting in-depth interviews and collecting reflective diaries kept by two members of each group. Results: During the study, one group ceased to operate. This was a group which refused to adopt the institutional rules and norms of managerial discourse. The other four groups survived by navigating the changing environment which existed at the time of the study, although often at some cost. Themes of autonomy and leadership were also identified. Conclusion: The current environment is one of the organisational complexity and change and the place of ULOs is an ambiguous one as they strive to maintain autonomy whilst at the same time being an acceptable voice to managers. [ABSTRACT FROM AUTHOR]

The National Health Service Institute for Innovation and Improvement was established to help the NHS to improve healthcare by rapidly developing and disseminating knowledge and evidence about new ways of working. One example is the Emergency and Urgent Care Pathway for Children and Young People which focused on providing high quality and safe healthcare for children and young people requiring urgent or emergency treatment for the most common illnesses and injuries. Monkey’s Guide to Healthy Living and NHS Services was developed to increase awareness of acute health services in primary school-aged children. This free resource was posted to every primary school in England. A process and impact evaluation was undertaken to explore how the resource was being utilized during 2013–2014. A small number of in-depth case studies were developed involving classroom-based observations and teacher interviews along with a much larger online survey which was emailed to all primary schools in England. On the whole, the resource was viewed as useful, engaging, and informative; with children, teachers, and other professionals particularly valuing the monkey puppet, video clips, and teacher resources. The National Evaluation highlighted that most respondents integrated the materials into the curriculum, used them as a one-off lesson, or developed their own innovative and strategic approaches to make the best use of the resources; almost two-thirds of schools who responded to the survey felt the resources led to pupils knowing about the available NHS services and healthy lifestyles; over half felt pupils were now more informed about the most appropriate services to use. [ABSTRACT FROM PUBLISHER]

Objective: To assess the performance of the universal newborn hearing screen in England. Design: Retrospective analysis of population screening records. Study sample: A total of 4 645 823 children born 1 April 2004 to 31 March 2013. Results: 97.5% of the eligible population complete screening by 4/5 weeks of age and 98.9% complete screening by three months of age. The refer rate for the 12/13 birth cohort is 2.6%. The percentage of screen positive (i.e. referred) babies commencing follow up by four weeks of age and six months of age is 82.5% and 95.8% respectively. The yield of bilateral PCHL from the screen is around 1/1000. For bilateral PCHL in the 12/13 birth cohort the median age is nine days at screen completion, 30 days at entry into follow up, 49 days at confirmation, 50 days at referral to early intervention, and 82 days at hearing-aid fitting. Conclusion: The performance of the newborn hearing screening programme has improved continuously. The yield of bilateral PCHL from the screen is about 1/1000 as expected. The age of identification and management is well within the first six months of life, although there remains scope for further improvement with respect to timely entry into follow up. [ABSTRACT FROM AUTHOR]

Purpose To survey the current practice of cervical spine pain assessment in relation to vertebrobasilar artery insufficiency (VBI), attitudes toward guidelines, and the practice of achieving informed consent in advance of planned orthopaedic manual therapy interventions. Method A self-administered postal survey was validated and sent to 325 physiotherapists working in the National Health Service (NHS) and private musculoskeletal practices in the Dorset and Hampshire region. Results The response rate was 53% from NHS physiotherapists and 20% from private practice, overall 34% (n = 111). Compliance rates with published guidelines were 50.4%; the sample holds them in neutral opinion (51.4%), and also holds cervical manipulation in neutral opinion (n = 50; 45.5%). Of these, 30.4% of respondents use cervical manipulation; a practice more closely associated with male practitioners (Φ = 0.35 P < 0.001), most use non-manipulative techniques such as manual traction (86.3%) or mobilizations (96.1%) with exercise (99%) as these are believed to be just as effective. Conclusions Physiotherapists in this sample do not appear to be adopting the VBI guidelines out of confidence or acknowledgment of their validity, but as a means to satisfy legality (76%) and enjoy that security (57.7%). Cervical spine assessment by a physiotherapist may be reliant on detailed subjective assessment that lacks objective testing, which could limit the scope of clinical reasoning between diagnoses of vascular (VBI, arterial dissection) and vestibular sources of symptoms. Those physiotherapists who had not attended postgraduate cervical manual therapy courses were associated with not practicing in agreement with the published evidence base; this finding lends support to the argument for a formal restriction of cervical manipulation by physiotherapists until a minimal requirement of postgraduate training is completed. [ABSTRACT FROM AUTHOR]

Background: This article reports the results of a service evaluation designed to assess children's dream fulfillment charity, Dreams Come True. Aims and Objectives: With the objective to gain the opinions of those who have used and are involved with the charity, parents (n = 10), staff (n = 10), and key informants (n = 18) were asked what the charity does most and least well. Method: Focus group meetings using the nominal group technique were held for parents and staff and an email survey was sent to key informants. Results: Conclusions, in the form of voted responses to the question of what the charity does most and least well are presented. Conclusions: Popular themes arising from each group were the benefit of dreams, the importance of empathy, staff communication, and fundraising. Implications for the charity and third sector are discussed. [ABSTRACT FROM AUTHOR]

Focus groups and a discrete choice experiment survey were conducted to inform a persuasive communications campaign to reduce non-urgent Accident and Emergency (A&E) attendance. One hundred and sixty-eight response questionnaires were included in the final analysis. The research found that respondents generally saw themselves as 'sensible' users of National Health Services (NHSs) and they felt that they think carefully before deciding which NHS to engage with. It was also felt that a lack of understanding, was the most powerful barrier to appropriate use of non-urgent and emergency services, with people not knowing what else is available, not knowing how to find alternative services and not understanding the 'healthcare system'. Broadly, there are four generic barriers to appropriate use of services: Therefore, to respond to this lack of understanding and reduce the perceived barriers, a marketing communications campaign will need to concentrate on creating a conversation about 'what to do when you do not know where to go and you are not sure how bad things are', invoking new beliefs and values rather than focusing on what to do when something is 'urgent'. Any marketing campaign will ultimately need to focus on stopping people accessing urgent healthcare services incorrectly. Therefore, when individuals are assessing the circumstances and the 'potential seriousness' of the condition in terms of pain or discomfort, they believe the benefits of attending non-A&E services, i.e. primary care outweigh the perceived 'convenience' of attending A&E and that these actions are indeed possible and easily accessible. Influences on choices to inform a persuasive communications campaign to reduce non-urgent A&E attendance. [ABSTRACT FROM AUTHOR]