Search

Background: 'Embedded research' (co-locating researchers within non-academic organisations) is advocated as a way of developing more effective services through better creation and application of knowledge. Aims and objectives: The existing literature on embedded initiatives has largely been descriptive. There has been less in the way of analysis, for example, disaggregating the components of such schemes, unpacking underpinning logics, or comparing the diverse ways in which schemes are instantiated. We aimed to explore the nature and organisation of such schemes in health settings in the UK, with the objective of providing a systematised means of understanding their makeup. Methods: This study uses a focused literature review combined with a systematic scoping exercise of extant initiatives. We assembled documentation on each scheme (n=45) and conducted in-depth interviews in twelve of them (n=17). Analytically, we focused on surfacing and articulating the key features of embedded research initiatives in relation to their intent, structure and processes. Findings were then tested and validated during a co-production workshop with embedded researchers and their managers. Findings: We identified 26 'clusters' of peer-reviewed papers detailing specific embedded research initiatives, and we explored 45 extant initiatives. The initiatives were varied in intent, structure and processes, but we were able to surface ten themes representing common features: intended outcomes, power dynamics, scale, involvement, proximity, belonging, functional activities, skill and expertise, relational roles, and learning and reflection. Discussion and conclusion: The themes uncovered can be used as a framework for guiding further systematic and evaluative enquiry on embedded research initiatives.

Background: Embedded research involves co-locating researchers within non-academic organisations to better link research and practice. Embedded research initiatives are often complex and emergent with a range of underlying intents, structures and processes. This can create tensions within initiatives and contributes to ongoing uncertainty about the most suitable designs and the effectiveness of different approaches. Aims and objectives: We aimed to devise a practical framework to support those designing and cultivating embedded research by operationalising findings from an extensive study of existing initiatives. Key conclusions: The underpinning research on embedded initiatives -- a literature review and scoping exercise of initiatives in health settings across the UK -- showed that such initiatives share ten common sets of concerns in relation to their intent, structure and processes. We used these insights during a co-production workshop with embedded researchers and their managers that made use of a range of creative activities. The workshop resulted in a practical framework (and associated web-based tools) that draw on the metaphor of a garden to represent the growing, emergent nature of embedded research initiatives and the active work which individuals and organisations need to put into planning and maintaining such initiatives. Each of the aspects is represented as a separate area within the garden using relevant visual metaphors. Building on this, we also present a series of reflective questions designed to facilitate discussion and debate about design features, and we link these to the wider literature, thereby helping those involved to articulate and discuss their preferences and expectations.

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]

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]

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]

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]

The author shares his views about the status and contribution of general practice or family medicine in the National Health Service (NHS) in Great Britain. Topics discussed include policymakers' focus on the hospital sector, thus taking for granted general practice, the decline in the budget allocated by the NHS to general practice, and ways to attract more physicians and nurses into general practice.

The author reflects on the status of general practice, its politics and possibilities in Great Britain. He says that general practitioners (GPs) should listen to criticisms even if they are not from patients because they can affect the reputation of the practice. He adds that GPs are no longer leaders in quality medical care because of reluctance to use new methods and reliance on standards rather than dynamic approach. To restore the role of GPs in the profession, he urges GPs to be committed as being excellent medical generalists and whole person care.

Objectives: To investigate how general medical practices in the UK react to bureaucratic initiatives, such as National Health Service (NHS) National Service Frameworks (NSFs), and to explore the value of the metaphor of 'barriers to change' for understanding this. Methods: Interviews, non-participant observation and documentary analysis within case studies of four practices in northern England. Results: The practices had not actively implemented NSFs. At interview, various 'barriers' that had prevented implementation were listed, including the complexity of the documents and lack of time. Observation suggested that these barriers were constructions used by the participants to make sense of the situation in which they found themselves. Conclusion: The metaphor of 'removing barriers to change' was of limited use in a context where non-implementation of policy was an emergent property of underlying organizational realities, likely to be modifiable only if these realities were addressed. [ABSTRACT FROM AUTHOR]

In this article, the authors discuss the role of action research in relation to the investigation and practical implementation of innovations in health care. The diffusion of innovations is an essential component of the modernization of health services worldwide. However, the literature shows that it is not an easy process to research. A paradox is noted that although action research has much to otter, it has had only a limited impact in the innovation field. Drawing on an example of a project in the United Kingdom, the authors discuss whether action research is a valuable method in the study of the diffusion of innovations. They analyze its strengths and limitations as a "whole systems approach" that combines researching with developing and diffusing innovations. They argue that it is best suited to the study of innovation diffusion where there is a need for high level of adaptation in each new setting. [ABSTRACT FROM AUTHOR]

Objective The publication of information about the performance of health-care providers is regarded as central to promoting greater accountability and empowering patients to exercise choice. The evidence suggests that the public is not very interested in accessing or using current sources of information. This study aimed to explore the information needs of patients in the context of UK primary care and to develop an information source about general practice services, designed to be usable by and useful to patients. Design An action research study making use of data from formal and informal interviews, focus groups, participant observation and document review. Setting The geographical areas covered by two Primary Care Trusts in the north of England and two Local Health Boards in south Wales. Participants A partnership between 103 members of the public, general practice staff from 19 practices, NHS managers from four Primary Care Organizations and the research team. Results The public would like to know more about the quality and range of general practice services but current sources of information do not meet their needs. The public do not like league tables comparing the performance of practices and only a small number of people want to use comparative information to choose between practices. They seem to be more interested in the context and availability of services and the willingness of practices to improve, than in the practice's absolute or relative performance. They want to be clear about the source of the information so that they can make personal judgements about its veracity. Information is most likely to be useful if it adheres to the basic principles of cognitive science in terms of its structure, content and presentation format. Using these findings, paper and electronic prototype versions of a guide to general practice services have been developed. Conclusions In order to maximize the potential use of performance information by the public it is necessary to move beyond provider-led and professionally constructed approaches to information provision and ensure that the public is actively involved in the development of information sources. Such involvement produces a different kind of information to that currently available to the public. The findings of this study have important implications for policy. Most importantly, it seems that the traditional consumerist model underlying a policy of making comparative performance information available to the public to enable them to exercise choice between primary care providers may not be appropriate. An alternative model of information provision, which recognizes the public's commitment to their practice and is integrated with ‘soft’ sources of knowledge is more likely to engage and be of use to the public. [ABSTRACT FROM AUTHOR]

Background: The relationship between effective organisation of general practices and health improvement is widely accepted. The Maturity Matrix is an instrument designed to assess organisational development in general practice settings and to stimulate quality improvement. It is undertaken by a practice team with the aid of a facilitator. There is a tradition in the primary care systems in many countries of using practice visitors to educate practice teams about how to improve. However the role of practice visitors as facilitators who enable teams to plan practiceled organisational development using quality improvement instruments is less well understood. The objectives of the study were to develop and explore a facilitation model to support practice teams in stimulating organisational development using a quality improvement instrument called the Maturity Matrix. A qualitative study based on transcript analysis was adopted. Method: A model of facilitation was constructed based on a review of relevant literature. Audio tapes of Maturity Matrix assessment sessions with general practices were transcribed and facilitator skills were compared to the model. The sample consisted of two facilitators working with twelve general practices based in UK primary care. Results: The facilitation model suggested that four areas describing eighteen skills were important. The four areas are structuring the session, obtaining consensus, handling group dynamics and enabling team learning. Facilitators effectively employed skills associated with the first three areas, but less able to consistently stimulate team learning. Conclusion: This study suggests that facilitators need careful preparation for their role and practices need protected time in order to make best use of practice-led quality improvement instruments. The role of practice visitor as a facilitator is becoming important as the need to engender ownership of the quality improvement process by practices increases. [ABSTRACT FROM AUTHOR]

This article reports on general practice in the United Kingdom, which is about to lose its near monopoly in the provision of primary care services. The established model of general practice is popular with patients and contributes to the quality, efficiency, and equity of the National Health Service, yet its responsiveness to patients' expectations and preferences could be improved. The introduction of greater competition may improve responsiveness but it has the potential to exacerbate inequalities, increase costs, and reduce quality of care for people dealing with multiple conditions.

Abstract Objectives To explore the potential tension between the need for managers to produce measurable change and the skills required to produce cultural change, and to investigate how managers of primary care trusts are attempting to deal with this tension. Design Qualitative case studies using data derived from semistructured interviews and a review of published documents. An established cultural framework was to used to help interpret the findings. Setting Six primary care trusts in England purposefully sampled to represent a range of cultural, structural, geographical, and demographic characteristics. Participants 42 interviews with 39 different senior and middle primary care trust managers conducted over an 18 month period. Results We found two distinct and polarised styles of management. One group of managers adopts a directive style and challenges the prevailing norms and values of clinicians, an approach characteristically seen in organisations with hierarchical cultures. This group is made up mostly of senior managers who are driven principally by the imperative to deliver a political agenda. Managers in the second group are more inclined to work with the prevailing cultures found in general practice, attempting to facilitate change from within rather than forcing change from outside. This management style is characteristically seen in organisations with a clan-type culture. The approach was manifest mostly by middle managers, who seem to act as buffers between the demands of senior managers and their own perception of the ability and willingness of health professionals to cope with change. The different management approaches can lead to tension and dysfunction between tiers of management. Conclusions The development of primary care depends on high quality managers who are able to draw on a range of different management skills and styles. Managers are most likely to be effective if they appreciate the merits and drawbacks of their different styles and are willing to work in partnership. [ABSTRACT FROM AUTHOR]

This paper reports the findings of a study concerned with the way in which Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) engaged with the Mental Health National Service Framework (NSF) as part of their remit to implement clinical governance. A qualitative multiple case study is reported which used semi-structured interviews and documentary analysis in a purposive sample of 12 PCG-Ts in England. The study found a general awareness of and support for the Mental Health NSF among PCG-Ts. In some localities the NSF acted to reinforce existing local developments in primary care mental health. However, compared to the NSF for Coronary Heart Disease a number of difficulties in responding to the Mental Health NSF were identified. These related to the perceived clinical status and complexity of managing mental health problems at practice level (e.g. familiarity with and competence of General Practitioners (GPs) in managing the conditions), inter-agency working, clinical governance training and the feasibility of producing clear demonstrable mental health outcomes as part of performance management. While the NSF for mental health presents opportunities for establishing the principles of quality assurance and improvement in the area of mental health, it is in danger of being marginalized in the clinical governance agendas of new PCTs, because of an inability to compete on an equal footing with other clinical priorities. While the partial demedicalisation of mental health is increasingly recognised as desirable for policy and therapeutic reasons the corollary is that it is harder to implement non-medicalised forms of care through the essentially medicalised apparatus of clinical governance. In order to deal with the complexities and challenges posed by the mental health agenda targeted support and resources are needed to promote clinical governance developments within primary care organisations. [ABSTRACT FROM AUTHOR]

Public disclosure of the comparative performance of health care providers has been proposed as one mechanism of improving the quality of care. Performance data have been made public in the USA for over a decade and the provision of comparative information about quality of care is a central feature of current UK government health policy. The balance between the advantages and risks of pursuing such a policy in a publicly funded health service is largely unknown. Advocates of public disclosure cite the role that comparative data can play in ensuring accountability, shifting the ownership of information (and therefore power) from professionals to service users and encouraging improvements in the processes and outcomes of care. However, these expectations are not necessarily realistic. There is some evidence that the public make little use of comparative data and there is a risk that public release may result in a loss of confidence in the health system and demoralisation of health service staff. In addition, there is a legitimate doubt that any early impact of disclosure will not be sustained and that the outcomes will not justify the necessary expenditure. In conclusion, we suggest that the theoretical benefits of promoting public disclosure as voiced by advocates of the policy may not be realised in practice. [ABSTRACT FROM AUTHOR]

Focuses on the application of qualitative medical research in examining the relationship between general practice physicians and specialists in a referral-based health service in Great Britain. Issues identified by the respondents relating to professional interaction; Illustration of the strengths and potential uses of qualitative research methods.

Presents a study on the barriers that health authorities face as they manage quality improvements in general medical practice in the context of the National Health Service reforms in Great Britain. Participants and methods; Results; Conclusion. INSET: Key messages.

Background: Buurtzorg, a model of community nursing conceived in the Netherlands, is widely cited as a promising and evidence-based approach to improving the delivery of integrated nursing and social care in community settings. The model is characterised by high levels of patient and staff satisfaction, professional autonomy exercised through self-managing nursing teams, client empowerment and holistic, patient centred care. This study aimed to examine the extent to which some of the principles of the Buurtzorg model could be adapted for community nursing in the United Kingdom.Methods: A community nursing model based on the Buurtzorg approach was piloted from June 2017-August 2018 with a team of nurses co-located in a single general practice in the Borough of Tower Hamlets, East London, UK. The initiative was evaluated using a participatory methodology known as the Researcher-in-Residence model. Qualitative data were collected using participant observation of meetings and semi-structured interviews with nurse team members, senior managers, patients/carers and other local stakeholders such as General Practitioners (GP) and social workers. A thematic framework analysis of the data was carried out.Results: Implementation of a community nursing model based on the Buurtzorg approach in East London had mixed success when assessed against its key principles. Patient experience of the service was positive because of the better access, improved continuity of care and longer appointment times in comparison with traditional community nursing provision. The model also provided important learning for developing service integration in community care, in particular, how to form effective collaborations across the care system with other health and social care professionals. However, some of the core features of the Buurtzorg model were difficult to put into practice in the National Health Service (NHS) because of significant cultural and regulatory differences between The Netherlands and the UK, especially the nurses' ability to exercise professional autonomy.Conclusions: Whilst many of the principles of the Buurtzorg model are applicable and transferable to the UK, in particular promoting independence among patients, improving patient experience and empowering frontline staff, the successful embedding of these aims as normalised ways of working will require a significant cultural shift at all levels of the NHS. [ABSTRACT FROM AUTHOR]

The establishment of The National Clinical Assessment Authority provides a new approach to the problem of poorly performing doctors. It is opined that medical self-regulation has traditionally been jealously guarded and enshrined in statute. The Performance Assessment Framework and the National Patient and User Survey both scrutinize, in quantitative terms, comparative performance in a very public way. At the same time, reform of the general medical council (GMC) and the development of revalidation have sought to bolster self-regulatory approaches and shore up trust in professionalism. Ambiguity over the acceptability of performance arises because of the uncertain nature of disease identification, prognosis prediction and treatment effectiveness. In order to be surer of identifying important departures from acceptable performance, there is an increasing risk of falsely labelling normal practice as aberrant. The recent high profile of malpractice and poor performance dealt with by the GMC, including the focus on the three medical individuals at the centre of the Bristol paediatric cardiac surgery scandal, actually obscure some more important shifts in the understanding on which current health policy is based.

The author discusses the risk of financial incentives such as the Quality and Outcomes Framework (QOF) in general practice. Topics discussed include the approach of the National Institute for Health and Care Excellence to assess indicators of the QOF, the six direct enhanced services (DESs) implemented in England to incentivised clinical behaviours such unplanned admissions and learning disability, and the benefits of co-creation in the practice to achieve quality improvement.

The author argues that the health sector of Great Britain can learn from the manufacturing sector's approach to enhancing quality care. He mentions that the manufacturing sector has adopted techniques like statistical process control and effective teamwork. He references reports published by the National Health Service (NHS) Institute for Innovation and Improvement and NHS Quality Improvement Scotland in 2009. Base on the findings of the report, the author suggests ways of how to improve quality care in the health sector.

The author reflects on the importance of revalidation to general practitioners (GPs) in Great Britain. He says that the publication "Guide to the Revalidation of General Practitioners" from the Royal College of General Practitioners (RCGP) offers an opportunity for GPs to be involved in changing the medical profession and society. He adds that revalidation promotes continuing professional development. He notes that the standardised multi-source feedback from peers suggested by the publication will pose challenge to GPs to improve their competence.

The author reflects on the future for trainee doctors in Great Britain. He suggests that the country's Tooke report has identified the challenges in the country's specialty training programs and the medical profession must respond to the challenges. He argues that the interests of patients, the National Health Service, and the medical profession will be met only if several deficiencies in the country's Modernising Medical Careers program are fixed quickly.

Focuses on the relationship between doctors and managers in Great Britain. Reasons for the rejection of the contract for United Kingdom physician consultants; History of the controversy between doctors and managers; Suggestion that differences in roles and responsibilities may contribute to tensions; The need to identify the problems and look for solutions.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

Background: Routinely recorded primary care data have been used for many years by sentinel networks for surveillance. More recently, real world data have been used for a wider range of research projects to support rapid, inexpensive clinical trials. Because the partial national lockdown in the United Kingdom due to the coronavirus disease (COVID-19) pandemic has resulted in decreasing community disease incidence, much larger numbers of general practices are needed to deliver effective COVID-19 surveillance and contribute to in-pandemic clinical trials., Objective: The aim of this protocol is to describe the rapid design and development of the Oxford Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) and its first two platforms. The Surveillance Platform will provide extended primary care surveillance, while the Trials Platform is a streamlined clinical trials platform that will be integrated into routine primary care practice., Methods: We will apply the FAIR (Findable, Accessible, Interoperable, and Reusable) metadata principles to a new, integrated digital health hub that will extract routinely collected general practice electronic health data for use in clinical trials and provide enhanced communicable disease surveillance. The hub will be findable through membership in Health Data Research UK and European metadata repositories. Accessibility through an online application system will provide access to study-ready data sets or developed custom data sets. Interoperability will be facilitated by fixed linkage to other key sources such as Hospital Episodes Statistics and the Office of National Statistics using pseudonymized data. All semantic descriptors (ie, ontologies) and code used for analysis will be made available to accelerate analyses. We will also make data available using common data models, starting with the US Food and Drug Administration Sentinel and Observational Medical Outcomes Partnership approaches, to facilitate international studies. The Surveillance Platform will provide access to data for health protection and promotion work as authorized through agreements between Oxford, the Royal College of General Practitioners, and Public Health England. All studies using the Trials Platform will go through appropriate ethical and other regulatory approval processes., Results: The hub will be a bottom-up, professionally led network that will provide benefits for member practices, our health service, and the population served. Data will only be used for SQUIRE (surveillance, quality improvement, research, and education) purposes. We have already received positive responses from practices, and the number of practices in the network has doubled to over 1150 since February 2020. COVID-19 surveillance has resulted in tripling of the number of virology sites to 293 (target 300), which has aided the collection of the largest ever weekly total of surveillance swabs in the United Kingdom as well as over 3000 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serology samples. Practices are recruiting to the PRINCIPLE (Platform Randomised trial of INterventions against COVID-19 In older PeopLE) trial, and these participants will be followed up through ORCHID. These initial outputs demonstrate the feasibility of ORCHID to provide an extended national digital health hub., Conclusions: ORCHID will provide equitable and innovative use of big data through a professionally led national primary care network and the application of FAIR principles. The secure data hub will host routinely collected general practice data linked to other key health care repositories for clinical trials and support enhanced in situ surveillance without always requiring large volume data extracts. ORCHID will support rapid data extraction, analysis, and dissemination with the aim of improving future research and development in general practice to positively impact patient care., International Registered Report Identifier (irrid): DERR1-10.2196/19773., (©Simon de Lusignan, Nicholas Jones, Jienchi Dorward, Rachel Byford, Harshana Liyanage, John Briggs, Filipa Ferreira, Oluwafunmi Akinyemi, Gayatri Amirthalingam, Chris Bates, Jamie Lopez Bernal, Gavin Dabrera, Alex Eavis, Alex J Elliot, Michael Feher, Else Krajenbrink, Uy Hoang, Gary Howsam, Jonathan Leach, Cecilia Okusi, Brian Nicholson, Philip Nieri, Julian Sherlock, Gillian Smith, Mark Thomas, Nicholas Thomas, Manasa Tripathy, William Victor, John Williams, Ian Wood, Maria Zambon, John Parry, Shaun O’Hanlon, Mark Joy, Chris Butler, Martin Marshall, FD Richard Hobbs. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 02.07.2020.)

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., Competing Interests: Competing interests: None declared., (© 2020 Joule Inc. or its licensors.)

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.

Objectives: To review some of the key debates relating to the nature of organizational culture and culture change care organizations and systems., Methods: A literature review was conducted that covered both theoretical contributions and published studies of the processes and outcomes of culture change programmes across a range of health and non-health care settings., Results: There is little consensus among scholars over the precise meaning of organizational culture. Competing claims exist concerning whether organizational cultures are capable of being shaped by external manipulation to beneficial effect. A range of culture change models has been developed. A number of underlying factors that commonly attenuate culture change programmes can be identified. Key factors that appear to impede culture change across a range of sectors include: inadequate or inappropriate leadership; constraints imposed by external stakeholders and professional allegiances; perceived lack of ownership; and subcultural diversity within health care organizations and systems., Conclusions: Managing organizational culture is increasingly viewed as an essential part of health system reform. To transform the culture of a whole health system such as the UK National Health Service would be a complex, multi-level, and uncertain process, comprising a range of interlocking strategies and supporting tactics unfolding over a period of years.

Background: It is commony claimed that changing the culture of health organisations is a fundamental prerequisite for improving the National Health Service (NHS). Little is currently known about the nature or importance of culture and cultural change in primary care groups and trusts (PCG/Ts) or their constituent general practices., Aims: To investigate the importance of culture and cultural change for the implementation of clinical governance in general practice by PCG/Ts, to identify perceived desirable and undesirable cultural attributes of general practice, and to describe potential facilitators and barriers to changing culture., Design: Qualitative: case studies using data derived from semi-structured interviews and review of documentary evidence., Setting: Fifty senior non-clinical and clinical managers from 12 purposely sampled PCGs or trusts in England., Results: Senior primary care managers regard culture and cultural change as fundamental aspects of clinical governance. The most important desirable cultural traits were the value placed on a commitment to public accountability by the practices, their willingness to work together and learn from each other, and the ability to be self-critical and learn from mistakes. The main barriers to cultural change were the high level of autonomy of practices and the perceived pressure to deliver rapid measurable changes in general practice., Conclusions: The culture of general practice is perceived to be an important component of health system reform and quality improvement. This study develops our understanding of a changing organisational culture in primary care; however, further work is required to determine whether culture is a useful practical lever for initiating or managing improvement.