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Grigoroglou C, Walshe K, Kontopantelis E, Ferguson J, Stringer G, Ashcroft DM, Allen T. Comparing the clinical practice and prescribing safety of locum and permanent doctors: observational study of primary care consultations in England. BMC Med 2024; 22:126. [PMID: 38532468 DOI: 10.1186/s12916-024-03332-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Temporary doctors, known as locums, are a key component of the medical workforce in the NHS but evidence on differences in quality and safety between locum and permanent doctors is limited. We aimed to examine differences in the clinical practice, and prescribing safety for locum and permanent doctors working in primary care in England. METHODS We accessed electronic health care records (EHRs) for 3.5 million patients from the CPRD GOLD database with linkage to Hospital Episode Statistics from 1st April 2010 to 31st March 2022. We used multi-level mixed effects logistic regression to compare consultations with locum and permanent GPs for several patient outcomes including general practice revisits; prescribing of antibiotics; strong opioids; hypnotics; A&E visits; emergency hospital admissions; admissions for ambulatory care sensitive conditions; test ordering; referrals; and prescribing safety indicators while controlling for patient and practice characteristics. RESULTS Consultations with locum GPs were 22% more likely to involve a prescription for an antibiotic (OR = 1.22 (1.21 to 1.22)), 8% more likely to involve a prescription for a strong opioid (OR = 1.08 (1.06 to 1.09)), 4% more likely to be followed by an A&E visit on the same day (OR = 1.04 (1.01 to 1.08)) and 5% more likely to be followed by an A&E visit within 1 to 7 days (OR = 1.05 (1.02 to 1.08)). Consultations with a locum were 12% less likely to lead to a practice revisit within 7 days (OR = 0.88 (0.87 to 0.88)), 4% less likely to involve a prescription for a hypnotic (OR = 0.96 (0.94 to 0.98)), 15% less likely to involve a referral (OR = 0.85 (0.84 to 0.86)) and 19% less likely to involve a test (OR = 0.81 (0.80 to 0.82)). We found no evidence that emergency admissions, ACSC admissions and eight out of the eleven prescribing safety indicators were different if patients were seen by a locum or a permanent GP. CONCLUSIONS Despite existing concerns, the clinical practice and performance of locum GPs did not appear to be systematically different from that of permanent GPs. The practice and performance of both locum and permanent GPs is likely shaped by the organisational setting and systems within which they work.
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Affiliation(s)
- Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Jane Ferguson
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Gemma Stringer
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
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Lamont T, Chatfield C, Walshe K. Developing the future research agenda for the health and social care workforce in the United Kingdom: Findings from a national forum for policymakers and researchers. Int J Health Plann Manage 2024. [PMID: 38326287 DOI: 10.1002/hpm.3775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/17/2024] [Accepted: 01/25/2024] [Indexed: 02/09/2024] Open
Abstract
There is a gap between healthcare workforce research and decision-making in policy and practice. This matters more than ever given the urgent staffing crisis. As a national research network, we held the first ever United Kingdom (UK) forum on healthcare workforce evidence in March 2023. This paper summarises outputs of the event including an emerging UK healthcare workforce agenda and actions to build research capacity and bridge the gap between academics and decisionmakers. The forum brought together over 80 clinical and system leaders, policymakers and regulators with workforce researchers. Fifteen sessions convened by leading experts combined knowledge exchange with deliberative dialogue over 2 days. Topics ranged from workforce analytics, forecasting, international migration to interprofessional working. In the small groups that were convened, important gaps were identified in both the existing research body and uptake of evidence already available. There had not been enough high quality evaluations of recent workforce initiatives implemented at pace, from virtual wards to e-rostering. The pandemic had accelerated many changes in skillmix and professional roles with little learning from other countries and systems. Existing research was often small-scale or focused on individual, rather than organisational solutions in areas such as staff wellbeing. In terms of existing research, managers were often unaware of accepted high quality evidence in areas like the relationship between registered nurse staffing levels and patient outcomes. More work is needed to engage new disciplines from labour economics and occupational health to academic human resources and to strengthen the emerging diverse community of healthcare workforce researchers.
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Affiliation(s)
- Tara Lamont
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
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Downes SG, Owens RA, Walshe K, Fitzpatrick DA, Dorey A, Jones GW, Doyle S. Gliotoxin-mediated bacterial growth inhibition is caused by specific metal ion depletion. Sci Rep 2023; 13:16156. [PMID: 37758814 PMCID: PMC10533825 DOI: 10.1038/s41598-023-43300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/21/2023] [Indexed: 09/29/2023] Open
Abstract
Overcoming antimicrobial resistance represents a formidable challenge and investigating bacterial growth inhibition by fungal metabolites may yield new strategies. Although the fungal non-ribosomal peptide gliotoxin (GT) is known to exhibit antibacterial activity, the mechanism(s) of action are unknown, although reduced gliotoxin (dithiol gliotoxin; DTG) is a zinc chelator. Furthermore, it has been demonstrated that GT synergises with vancomycin to inhibit growth of Staphylococcus aureus. Here we demonstrate, without precedent, that GT-mediated growth inhibition of both Gram positive and negative bacterial species is reversed by Zn2+ or Cu2+ addition. Both GT, and the known zinc chelator TPEN, mediate growth inhibition of Enterococcus faecalis which is reversed by zinc addition. Moreover, zinc also reverses the synergistic growth inhibition of E. faecalis observed in the presence of both GT and vancomycin (4 µg/ml). As well as zinc chelation, DTG also appears to chelate Cu2+, but not Mn2+ using a 4-(2-pyridylazo)resorcinol assay system and Zn2+ as a positive control. DTG also specifically reacts in Fe3+-containing Siderotec™ assays, most likely by Fe3+ chelation from test reagents. GSH or DTT show no activity in these assays. Confirmatory high resolution mass spectrometry, in negative ion mode, confirmed, for the first time, the presence of both Cu[DTG] and Fe[DTG]2 chelates. Label free quantitative proteomic analysis further revealed major intracellular proteomic remodelling within E. faecalis in response to GT exposure for 30-180 min. Globally, 4.2-7.2% of detectable proteins exhibited evidence of either unique presence/increased abundance or unique absence/decreased abundance (n = 994-1160 total proteins detected), which is the first demonstration that GT affects the bacterial proteome in general, and E. faecalis, specifically. Unique detection of components of the AdcABC and AdcA-II zinc uptake systems was observed, along with apparent ribosomal reprofiling to zinc-free paralogs in the presence of GT. Overall, we hypothesise that GT-mediated bacterial growth inhibition appears to involve intracellular zinc depletion or reduced bioavailability, and based on in vitro chelate formation, may also involve dysregulation of Cu2+ homeostasis.
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Affiliation(s)
- Shane G Downes
- Department of Biology, Maynooth University, Co. Kildare, Ireland
| | - Rebecca A Owens
- Department of Biology, Maynooth University, Co. Kildare, Ireland
| | | | | | - Amber Dorey
- Molecular Parasitology, University of Galway, Galway, Ireland
| | - Gary W Jones
- Centre for Biomedical Science Research, School of Health, Leeds-Beckett University, Leeds, UK.
| | - Sean Doyle
- Department of Biology, Maynooth University, Co. Kildare, Ireland.
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Stringer G, Ferguson J, Walshe K, Grigoroglou C, Allen T, Kontopantelis E, Ashcroft DM. Locum doctors in English general practices: evidence from a national survey. Br J Gen Pract 2023; 73:e667-e676. [PMID: 37604697 PMCID: PMC10471140 DOI: 10.3399/bjgp.2023.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/16/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Locum doctors give practices flexibility to deliver patient services but there are concerns about the impact of locum working on continuity of care, patient safety, team function, and cost. AIM To explore locum working in English general practices, and understand why and where locum doctors were needed and how they were engaged, supported, perceived, and managed. DESIGN AND SETTING An online survey was sent to 3745 practices. METHOD Quantitative responses were analysed using frequency tables, t-tests, and correlations. Free-text responses were analysed using thematic analysis. RESULTS In total, 605 (16.2%) responses were returned between June and December 2021. Practices made frequent use of locums, preferring regular locums familiar with processes and patients. Disadvantages of agency locums included cost, lack of patient familiarity, and impact on continuity of care. Care provided by locums was generally viewed as the same but sometimes worse compared with permanent GPs. Some practices reported that locums did not always perform the full range of duties, resulting in increased workload for other staff. Practices were largely unfamiliar with national guidance for organisations engaging locums, and, although processes such as verifying documentation were conducted, far fewer responders reported providing feedback, support for revalidation, or professional development. CONCLUSION Locum working is an essential part of English general practice, but this research raises some concerns about the robustness of arrangements for locum working and the impact on quality and safety of care. Further research is needed about the clinical practice and performance of locums, and to explore how locum working can be organised in ways that assure safe and high-quality care.
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Affiliation(s)
- Gemma Stringer
- Alliance Manchester Business School, Institute for Health Policy and Organisation, University of Manchester, Manchester, UK
| | - Jane Ferguson
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Kieran Walshe
- Alliance Manchester Business School, Institute for Health Policy and Organisation, University of Manchester, Manchester, UK
| | - Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK; Danish Centre for Health Economics, University of Southern Denmark, Denmark
| | - Evangelos Kontopantelis
- National Institute for Health and Care Research School for Primary Care Research, Centre for Primary Care and Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
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Stringer G, Ferguson J, Walshe K, Grigoroglou C, Allen T, Kontopantelis E, Ashcroft DM. The use of locum doctors in the NHS - results of a national survey of NHS Trusts in England. BMC Health Serv Res 2023; 23:889. [PMID: 37612669 PMCID: PMC10464080 DOI: 10.1186/s12913-023-09830-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/18/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Locum working in healthcare organisations has benefits for individual doctors and organisations but there are concerns about the impact of locum working on continuity of care, patient safety, team function and cost. We conducted a national survey of NHS Trusts in England to explore locum work, and better understand why and where locum doctors were needed; how locum doctors were engaged, supported, perceived and managed; and any changes being made in the way locums are used. METHODS An online survey was sent to 191 NHS Trusts and 98 were returned (51%) including 66 (67%) acute hospitals, 26 (27%) mental health and six (6%) community health providers. Data was analysed using frequency tables, t-tests and correlations. Free-text responses were analysed using thematic analysis. RESULTS Most NHS Trusts use locums frequently and for varying lengths of time. Trusts prefer to use locums from internal locum banks but frequently rely on locum agencies. The benefits of using locums included maintaining workforce capacity and flexibility. Importantly, care provided by locums was generally viewed as the same or somewhat worse when compared to care provided by permanent doctors. The main disadvantages of using locum agencies included cost, lack of familiarity and impact on organisational development. Some respondents felt that locums could be unreliable and less likely to be invested in quality improvement. NHS Trusts were broadly unfamiliar with the national guidance from NHS England for supporting locums and there was a focus on processes like compliance checks and induction, with less focus on providing feedback and support for appraisal. CONCLUSIONS Locum doctors provide a necessary service within NHS Trusts to maintain workforce capacity and provide patient care. There are potential issues related to the way that locums are perceived, utilised, and supported which might impact the quality of the care that they provide. Future research should consider the arrangements for locum working and the performance of locums and permanent doctors, investigating the organisation of locums in order to achieve safe and high-quality care for patients.
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Affiliation(s)
- Gemma Stringer
- Alliance Manchester Business School, Institute for Health Policy and Organisation, The University of Manchester, Booth Street West, Manchester, M15 6PB UK
| | - Jane Ferguson
- Alliance Manchester Business School, Institute for Health Policy and Organisation, The University of Manchester, Booth Street West, Manchester, M15 6PB UK
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Kieran Walshe
- Alliance Manchester Business School, Institute for Health Policy and Organisation, The University of Manchester, Booth Street West, Manchester, M15 6PB UK
| | - Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, UK
| | - Darren M. Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Affiliation(s)
- Tara Lamont
- Health Services Research UK
- THIS Institute, University of Cambridge, UK
| | | | - Kieran Walshe
- Health Services Research UK
- University of Manchester, UK
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Snooks H, Khanom A, Ballo R, Bower P, Checkland K, Ellins J, Ford GA, Locock L, Walshe K. Is bureaucracy being busted in research ethics and governance for health services research in the UK? Experiences and perspectives reported by stakeholders through an online survey. BMC Public Health 2023; 23:1119. [PMID: 37308950 PMCID: PMC10258770 DOI: 10.1186/s12889-023-16013-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND It has long been noted that the chain from identification of need (research gap) to impact in the real world is both long and tortuous. This study aimed to contribute evidence about research ethics and governance arrangements and processes in the UK with a focus on: what works well; problems; impacts on delivery; and potential improvements. METHODS Online questionnaire widely distributed 20th May 2021, with request to forward to other interested parties. The survey closed on 18th June 2021. Questionnaire included closed and open questions related to demographics, role, study objectives. RESULTS Responses were received from 252 respondents, 68% based in universities 25% in the NHS. Research methods used by respondents included interviews/focus groups (64%); surveys/questionnaires (63%); and experimental/quasi experimental (57%). Respondents reported that participants in the research they conducted most commonly included: patients (91%); NHS staff (64%) and public (50%). Aspects of research ethics and governance reported to work well were: online centralised systems; confidence in rigorous, respected systems; and helpful staff. Problems with workload, frustration and delays were reported, related to overly bureaucratic, unclear, repetitive, inflexible and inconsistent processes. Disproportionality of requirements for low-risk studies was raised across all areas, with systems reported to be risk averse, defensive and taking little account of the risks associated with delaying or deterring research. Some requirements were reported to have unintended effects on inclusion and diversity, particularly impacting Patient and Public Involvement (PPI) and engagement processes. Existing processes and requirements were reported to cause stress and demoralisation, particularly as many researchers are employed on fixed term contracts. High negative impacts on research delivery were reported, in terms of timescales for completing studies, discouraging research particularly for clinicians and students, quality of outputs and costs. Suggested improvements related to system level changes / overall approach and specific refinements to existing processes. CONCLUSIONS Consultation with those involved in Health Services Research in the UK revealed a picture of overwhelming and increasing bureaucracy, delays, costs and demoralisation related to gaining the approvals necessary to conduct research in the NHS. Suggestions for improvement across all three areas focused on reducing duplication and unnecessary paperwork/form filling and reaching a better balance between risks of harm through research and harms which occur because research to inform practice is delayed or deterred.
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Affiliation(s)
- Helen Snooks
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, SA2 8PP, UK.
| | - Ashrafunnesa Khanom
- Faculty of Medicine, Health and Life Science, Swansea University, Swansea, SA2 8PP, UK
| | - Rokia Ballo
- Nuffield Trust, 59 New Cavendish St, London, W1G 7LP, UK
| | - Peter Bower
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Katherine Checkland
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Jo Ellins
- Health Services Management Centre, School of Social Policy, University of Birmingham, Edgbaston, Birmingham, B15 2RT, UK
| | - Gary A Ford
- Oxford University, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Louise Locock
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Kieran Walshe
- HSR UK c/o Nuffield Trust, 59 New Cavendish St, London, W1G 7LP, UK
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Grigoroglou C, Walshe K, Kontopantelis E, Ferguson J, Stringer G, Ashcroft D, Allen T. Use of locum doctors in NHS trusts in England: analysis of routinely collected workforce data 2019-2021. BMJ Open 2023; 13:e065803. [PMID: 37230514 DOI: 10.1136/bmjopen-2022-065803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVES Temporary doctors, known as locum doctors, play an important role in the delivery of care in the National Health Service (NHS); however, little is known about the extent of locum use in NHS trusts. This study aimed to quantify and describe locum use for all NHS trusts in England in 2019-2021. SETTING Descriptive analyses of data on locum shifts from all NHS trusts in England in 2019-2021. Weekly data were available for the number of shifts filled by agency and bank staff and the number of shifts requested by each trust. Negative binomial models were used to investigate the association between the proportion of medical staffing provided by locums and NHS trust characteristics. RESULTS In 2019, on average 4.4% of total medical staffing was provided by locums, but this varied substantially across trusts (25th-75th centile=2.2%-6.2%). Over time, on average two-thirds of locum shifts were filled by locum agencies and a third by trusts' staff banks. On average, 11.3% of shifts requested were left unfilled. In 2019-2021, the mean number of weekly shifts per trust increased by 19% (175.2-208.6) and the mean number of weekly unfilled shifts per trust increased by 54% (32.7 to 50.4). Trusts rated by the Care Quality Commission (CQC) as inadequate or requiring improvement (incidence rate ratio=1.495; 95% CI 1.191 to 1.877), and smaller trusts had a higher use of locums. Large variability was observed across regions for use of locums, proportion of shifts filled by locum agencies and unfilled shifts. CONCLUSIONS There were large variations in the demand for and use of locum doctors in NHS trusts. Trusts with poor CQC ratings and smaller trusts appear to use locum doctors more intensively compared with other trust types. Unfilled shifts were at a 3-year high at the end of 2021 suggesting increased demand which may result from growing workforce shortages in NHS trusts.
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Affiliation(s)
- Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Kieran Walshe
- Alliance Manchester Business School, Institute for Health Policy and Organisation, The University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research, The University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, The University of Manchester, Manchester, UK
| | - Jane Ferguson
- Alliance Manchester Business School, Institute for Health Policy and Organisation, The University of Manchester, Manchester, UK
| | - Gemma Stringer
- Alliance Manchester Business School, Institute for Health Policy and Organisation, The University of Manchester, Manchester, UK
| | - Darren Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
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Curtis A, Walshe K, Kavanagh K. Prolonged Subculturing of Aspergillus fumigatus on Galleria Extract Agar Results in Altered Virulence and Sensitivity to Antifungal Agents. Cells 2023; 12:cells12071065. [PMID: 37048138 PMCID: PMC10093746 DOI: 10.3390/cells12071065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Aspergillus fumigatus is an environmental saprophyte and opportunistic fungal pathogen of humans. The aim of the work presented here was to examine the effect of serially subculturing A. fumigatus on agar generated from Galleria mellonella larvae in order to characterize the alterations in the phenotypes that might occur. The passaged strains showed alterations in virulence, antifungal susceptibility, and in protein abundances that may indicate adaptation after 25 passages over 231 days on Galleria extract agar. Passaged strains demonstrated reduced virulence in G. mellonella larvae and increased tolerance to hemocyte-mediated killing, hydrogen peroxide, itraconazole, and amphotericin B. A label-free proteomic analysis of control and passaged A. fumigatus strains revealed a total of 3329 proteins, of which 1902 remained following filtration, and 32 proteins were statistically significant as well as differentially abundant. Proteins involved in the response to oxidative stress were altered in abundance in the passaged strain and included (S)-S-oxide reductase (+2.63-fold), developmental regulator FlbA (+2.27-fold), and histone H2A.Z (−1.82-fold). These results indicate that the prolonged subculturing of A. fumigatus on Galleria extract agar results in alterations in the susceptibility to antifungal agents and in the abundance of proteins associated with the oxidative stress response. The phenomenon may be a result of selection for survival in adverse conditions and highlight how A. fumigatus may adapt to tolerate the pulmonary immune response in cases of human infection.
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Moloney NM, Larkin A, Xu L, Fitzpatrick DA, Crean HL, Walshe K, Haas H, Decristoforo C, Doyle S. Generation and characterisation of a semi-synthetic siderophore-immunogen conjugate and a derivative recombinant triacetylfusarinine C-specific monoclonal antibody with fungal diagnostic application. Anal Biochem 2021; 632:114384. [PMID: 34543643 DOI: 10.1016/j.ab.2021.114384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/16/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022]
Abstract
Invasive pulmonary aspergillosis (IPA) is a severe life-threatening condition. Diagnosis of fungal disease in general, and especially that caused by Aspergillus fumigatus is problematic. A. fumigatus secretes siderophores to acquire iron during infection, which are also essential for virulence. We describe the chemoacetylation of ferrated fusarinine C to diacetylated fusarinine C (DAFC), followed by protein conjugation, which facilitated triacetylfusarinine C (TAFC)-specific monoclonal antibody production with specific recognition of the ferrated form of TAFC. A single monoclonal antibody sequence was ultimately elucidated by a combinatorial strategy involving protein LC-MS/MS, cDNA sequencing and RNAseq. The resultant murine IgG2a monoclonal antibody was secreted in, and purified from, mammalian cell culture (5 mg) and demonstrated to be highly specific for TAFC detection by competitive ELISA (detection limit: 15 nM) and in a lateral flow test system (detection limit: 3 ng), using gold nanoparticle conjugated- DAFC-bovine serum albumin for competition. Overall, this work reveals for the first time a recombinant TAFC-specific monoclonal antibody with diagnostic potential for IPA diagnosis in traditional and emerging patient groups (e.g., COVID-19) and presents a useful strategy for murine Ig sequence determination, and expression in HEK293 cells, to overcome unexpected limitations associated with aberrant or deficient murine monoclonal antibody production.
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Affiliation(s)
- Nicola M Moloney
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland
| | - Annemarie Larkin
- National Institute for Cellular Biotechnology, Dublin City University, Dublin, Ireland
| | - Linan Xu
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland
| | - David A Fitzpatrick
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland
| | - Holly L Crean
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland
| | - Kieran Walshe
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland
| | - Hubertus Haas
- Institute of Molecular Biology, Medical University Innsbruck, A-6020, Innsbruck, Austria
| | - Clemens Decristoforo
- Department of Nuclear Medicine, Medical University Innsbruck, Anichstrasse 5, A-6020, Innsbruck, Austria
| | - Sean Doyle
- Department of Biology, Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland.
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Lorne C, Coleman A, McDonald R, Walshe K. Assembling the Healthopolis: Competitive city-regionalism and policy boosterism pushing Greater Manchester further, faster. Trans Inst Br Geogr 2021; 46:314-329. [PMID: 34262224 PMCID: PMC8252707 DOI: 10.1111/tran.12421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/10/2020] [Indexed: 06/13/2023]
Abstract
Health and care policy is increasingly promoted within visions of the competitive city-region. This paper examines the importance of policy boosterism within the political construction of city-regions in the context of English devolution. Based on a two-year case study of health and social care devolution in Greater Manchester, England, we trace the relational and territorial geographies of policy across and through new "devolved" city-regional arrangements. Contributing to geographical debates on policy assemblages and city-regionalism, we advance a conceptual framework linking crisis and opportunity, emulation and exceptionalism, and evidence and experimentation. The paper makes two key contributions. First, we argue health and care policy is increasingly drawn towards the logic of global competitiveness without being wholly defined by neoliberal political agendas. Fostering transnational policy networks helped embed global "best practice" policies while simultaneously hailing Greater Manchester as a place beyond compare. Second, we caution against positioning the city-region solely at the receiving end of devolutionary austerity. Rather, we illustrate how the urgency of devolution was conditioned by crisis, yet concomitantly framed as a unique opportunity by the local state harnessing policy to negotiate a more fluid politics of scale. In doing so, the paper demonstrates how attempts to resolve the "local problem" of governing health and care under austerity were rearticulated as a "global opportunity" to forge new connections between place, health, and economy. Consequently, we foreground the multiple tensions and contradictions accumulating through turning to health and care to push Greater Manchester further, faster. The paper concludes by asking what the present crisis might mean for city-regions in good health and turbulent times.
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Affiliation(s)
- Colin Lorne
- Geography, Faculty of Arts and Social SciencesThe Open UniversityMilton KeynesUK
| | - Anna Coleman
- Division of Population Health, Health Services Research and Primary CareUniversity of ManchesterManchesterUK
| | - Ruth McDonald
- Alliance Manchester Business SchoolUniversity of ManchesterManchesterUK
| | - Kieran Walshe
- Alliance Manchester Business SchoolUniversity of ManchesterManchesterUK
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Mansour W, Boyd A, Walshe K. National accreditation programmes for hospitals in the Eastern Mediterranean Region: Case studies from Egypt, Jordan, and Lebanon. Int J Health Plann Manage 2021; 36:1500-1520. [PMID: 33949699 DOI: 10.1002/hpm.3178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/21/2021] [Accepted: 04/07/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Many countries use external evaluation programmes such as accreditation in order to improve quality and safety in their healthcare settings. Hospital accreditation has developed in many low-and-middle-income countries (LMICs); however, the implementation and sustainability of these programmes vary in each country. This study addresses design and implementation issues of national hospital accreditation programmes. It identifies factors which may explain why programmes can be implemented successfully in one country but not in another and derives lessons for the design and implementation of national accreditation programmes in poor-resource settings. METHODS A multiple case study design was used, comprising three countries in the Eastern Mediterranean Region: Egypt, Lebanon and Jordan. In-depth semi-structured interviews were conducted with 27 key stakeholders in the three countries and experts from international organisations concerned with accreditation activities in LMICs. RESULTS The hospital accreditation programme was successful and sustainable in Jordan but experienced some difficulties in Egypt and Lebanon. The premature end of external funding and devastating political instability after the Arab Spring were problematic for the programmes in Egypt and Lebanon, but continuous funding and strong political will supported the implementation and sustainability of the programme in Jordan. CONCLUSIONS LMICs striving to improve their hospitals' performance through accreditation programmes should consider their vulnerability to a scarcity of financial resources and political instability. An important factor underpinning sustainability is recognising that the accreditation programme is an ongoing and developing quality improvement process that needs continuing and careful attention from funders and political systems if it is to survive and thrive.
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Affiliation(s)
- Wesam Mansour
- Department of Management and Policy, Alliance Manchester Business School, Manchester, UK
| | - Alan Boyd
- Department of Management and Policy, Alliance Manchester Business School, Manchester, UK
| | - Kieran Walshe
- Department of Management and Policy, Alliance Manchester Business School, Manchester, UK
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13
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Husabø G, Nilsen RM, Flaatten H, Solligård E, Frich JC, Bondevik GT, Braut GS, Walshe K, Harthug S, Hovlid E. Correction: Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study. PLoS One 2021; 16:e0248879. [PMID: 33720978 PMCID: PMC7959348 DOI: 10.1371/journal.pone.0248879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0227652.].
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Mansour W, Boyd A, Walshe K. The development of hospital accreditation in low- and middle-income countries: a literature review. Health Policy Plan 2021; 35:684-700. [PMID: 32268354 PMCID: PMC7294243 DOI: 10.1093/heapol/czaa011] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2020] [Indexed: 11/14/2022] Open
Abstract
Hospital accreditation has been transferred from high-income countries (HICs) to many low- and middle-income countries (LMICs), supported by a variety of advocates and donor agencies. This review uses a policy transfer theoretical framework to present a structured analysis of the development of hospital accreditation in LMICs. The framework is used to identify how governments in LMICs adopted accreditation from other settings and what mechanisms facilitated and hindered the transfer of accreditation. The review examines the interaction between national and international actors, and how international organizations influenced accreditation policy transfer. Relevant literature was found by searching databases and selected websites; 78 articles were included in the analysis process. The review concludes that accreditation is increasingly used as a tool to improve the quality of healthcare in LMICs. Many countries have established national hospital accreditation programmes and adapted them to fit their national contexts. However, the implementation and sustainability of these programmes are major challenges if resources are scarce. International actors have a substantial influence on the development of accreditation in LMICs, as sources of expertise and pump-priming funding. There is a need to provide a roadmap for the successful development and implementation of accreditation programmes in low-resource settings. Analysing accreditation policy processes could provide contextually sensitive lessons for LMICs seeking to develop and sustain their national accreditation programmes and for international organizations to exploit their role in supporting the development of accreditation in LMICs.
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Affiliation(s)
- Wesam Mansour
- Liverpool School of Tropical Medicine, Department of International Public Health, Pembroke Place, Liverpool L3 5QA, UK
| | - Alan Boyd
- Alliance Manchester Business School, Innovation, Policy and Management Department, University of Manchester, Booth Street West, Manchester M15 6PB, UK
| | - Kieran Walshe
- Alliance Manchester Business School, Innovation, Policy and Management Department, University of Manchester, Booth Street West, Manchester M15 6PB, UK
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Ferguson J, Tazzyman A, Walshe K, Bryce M, Boyd A, Archer J, Price T, Tredinnick-Rowe J. 'You're just a locum': professional identity and temporary workers in the medical profession. Sociol Health Illn 2021; 43:149-166. [PMID: 33112436 DOI: 10.1111/1467-9566.13210] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 06/11/2023]
Abstract
Internationally, there has been substantial growth in temporary working, including in the medical profession where temporary doctors are known as locums. There is little research into the implications of temporary work in health care. In this paper, we draw upon theories concerning the sociology of the medical profession to examine the implications of locum working for the medical profession, healthcare organisations and patient safety. We focus particularly on the role of organisations in professional governance and the positioning of locums as peripheral to or outside the organisation, and the influence of intergroup relationships (in this case between permanent and locum doctors) on professional identity. Qualitative semi-structured interviews were conducted between 2015 and 2017 in England with 79 participants including locum doctors, locum agency staff, and representatives of healthcare organisations who use locums. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation. Our findings suggest that locums were perceived to be inferior to permanently employed doctors in terms of quality, competency and safety and were often stigmatised, marginalised and excluded. The treatment of locums may have negative implications for collegiality, professional identity, group relations, team functioning and the way organisations deploy and treat locums may have important consequences for patient safety.
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Affiliation(s)
- Jane Ferguson
- Alliance Manchester Business School, Institute for Health Policy and Organisation, Manchester, UK
| | - Abigail Tazzyman
- Sheffield Methods Institute, University of Sheffield, Sheffield, UK
| | - Kieran Walshe
- Alliance Manchester Business School, Institute for Health Policy and Organisation, Manchester, UK
| | - Marie Bryce
- Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Peninsula Medical School, University of Plymouth Faculty of Health, Plymouth, UK
| | - Alan Boyd
- Alliance Manchester Business School, Institute for Health Policy and Organisation, Manchester, UK
| | - Julian Archer
- Faculty of Medicine, Nursing and Healthcare, Monash University, Melbourne, Australia
| | - Tristan Price
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
| | - John Tredinnick-Rowe
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
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Allen T, Walshe K, Proudlove N, Sutton M. Do performance indicators predict regulator ratings of healthcare providers? Cross-sectional study of acute hospitals in England. Int J Qual Health Care 2020; 32:113-119. [PMID: 31725874 PMCID: PMC7184898 DOI: 10.1093/intqhc/mzz101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/29/2019] [Accepted: 09/12/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine whether a large set of care performance indicators ('Intelligent Monitoring (IM)') can be used to predict the Care Quality Commission's (CQC) acute hospital trust provider ratings. DESIGN The IM dataset and first-inspection ratings were used to build linear and ordered logistic regression models for the whole dataset (all trusts). This was repeated for subsets of the trusts, with these models then applied to predict the inspection ratings of the remaining trusts. SETTING The United Kingdom Department of Health and Social Care's Care Quality Commission is the regulator for all health and social care services in England. We consider their first-inspection cycle of acute hospital trusts (2013-2016). PARTICIPANTS All 156 English NHS acute hospital trusts. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Percentage of correct predictions and weighted kappa. RESULTS Only 24% of the predicted overall ratings for the test sample were correct and the weighted kappa of 0.01 indicates very poor agreement between predicted and actual ratings. This lack of predictive power is also found for each of the rating domains. CONCLUSION While hospital inspections draw on a much wider set of information, the poor power of performance indicators to predict subsequent inspection ratings may call into question the validity of indicators, ratings or both. We conclude that a number of changes to the way performance indicators are collected and used could improve their predictive value, and suggest that assessing predictive power should be undertaken prospectively when the sets of indicators are being designed and selected by regulators.
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Affiliation(s)
- Thomas Allen
- Manchester Centre for Health Economics, University of Manchester, 4.305 Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Booth Street West, Manchester M15 6PB, UK
| | - Nathan Proudlove
- Alliance Manchester Business School, University of Manchester, Booth Street West, Manchester M15 6PB, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, Division of Population Health, Health Services Research & Primary Care, Williamson Building, Oxford Road, University of Manchester, Manchester M13 9QQ, UK
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Husabø G, Nilsen RM, Solligård E, Flaatten HK, Walshe K, Frich JC, Bondevik GT, Braut GS, Helgeland J, Harthug S, Hovlid E. Effects of external inspections on sepsis detection and treatment: a stepped-wedge study with cluster-level randomisation. BMJ Open 2020; 10:e037715. [PMID: 33082187 PMCID: PMC7577024 DOI: 10.1136/bmjopen-2020-037715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To evaluate the effects of external inspections on (1) hospital emergency departments' clinical processes for detecting and treating sepsis and (2) length of hospital stay and 30-day mortality. DESIGN Incomplete cluster-randomised stepped-wedge design using data from patient records and patient registries. We compared care processes and patient outcomes before and after the intervention using regression analysis. SETTING Nationwide inspections of sepsis care in emergency departments in Norwegian hospitals. PARTICIPANTS 7407 patients presenting to hospital emergency departments with sepsis. INTERVENTION External inspections of sepsis detection and treatment led by a public supervisory institution. MAIN OUTCOME MEASURES Process measures for sepsis diagnostics and treatment, length of hospital stay and 30-day all-cause mortality. RESULTS After the inspections, there were significant improvements in the proportions of patients examined by a physician within the time frame set in triage (OR 1.28, 95% CI 1.07 to 1.53), undergoing a complete set of vital measurements within 1 hour (OR 1.78, 95% CI 1.10 to 2.87), having lactate measured within 1 hour (OR 2.75, 95% CI 1.83 to 4.15), having an adequate observation regimen (OR 2.20, 95% CI 1.51 to 3.20) and receiving antibiotics within 1 hour (OR 2.16, 95% CI 1.83 to 2.55). There was also significant reduction in mortality and length of stay, but these findings were no longer significant when controlling for time. CONCLUSIONS External inspections were associated with improvement of sepsis detection and treatment. These findings suggest that policy-makers and regulatory agencies should prioritise assessing the effects of their inspections and pay attention to the mechanisms by which the inspections might contribute to improve care for patients. TRIAL REGISTRATION NCT02747121.
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Affiliation(s)
- Gunnar Husabø
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Roy Miodini Nilsen
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Erik Solligård
- Clinic of Anesthesia and Intensive Care, St. Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Kieran Walshe
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Jan C Frich
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Gunnar Tschudi Bondevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
| | - Geir Sverre Braut
- Department of Research, Stavanger University Hospital, Stavanger, Norway
- Department 5, Norwegian Board of Health Supervision, Oslo, Norway
| | | | - Stig Harthug
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Einar Hovlid
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department 5, Norwegian Board of Health Supervision, Oslo, Norway
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Hovlid E, Braut GS, Hannisdal E, Walshe K, Bukve O, Flottorp S, Stensland P, Frich JC. Mediators of change in healthcare organisations subject to external assessment: a systematic review with narrative synthesis. BMJ Open 2020; 10:e038850. [PMID: 32868366 PMCID: PMC7462249 DOI: 10.1136/bmjopen-2020-038850] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES External inspections are widely used to improve the quality of care. The effects of inspections remain unclear and little is known about how they may work. We conducted a narrative synthesis of research literature to identify mediators of change in healthcare organisations subject to external inspections. METHODS We performed a literature search (1980-January 2020) to identify empirical studies addressing change in healthcare organisations subject to external inspection. Guided by the Consolidated Framework for Implementation Research, we performed a narrative synthesis to identify mediators of change. RESULTS We included 95 studies. Accreditation was the most frequent type of inspection (n=68), followed by statutory inspections (n=19), and external peer review (n=9). Our findings suggest that the regulatory context in which the inspections take place affect how they are acted on by those being inspected. The way inspections are conducted seem to be critical for how the inspection findings are perceived and followed up. Inspections can engage and involve staff, facilitate leader engagement, improve communication and enable the creation of new networks for reflection on clinical practice. Inspections can contribute to creating an awareness of the inspected organisation's current practice and performance gaps, and a commitment to change. Moreover, they can contribute to facilitating the planning and implementation of change, as well as self-evaluation and the use of data to evaluate performance. CONCLUSIONS External inspections can affect different mediators of organisational change. The way and to what extent they do depend on a range of factors related to the outer setting, the way inspections are conducted and how they are perceived and acted on by the inspected organisation. To improve the quality of care, the organisational change processes need to involve and impact the way care is delivered to the patients.
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Affiliation(s)
- Einar Hovlid
- Institute of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, Universitetet i Bergen, Bergen, Norway
| | - Geir Sverre Braut
- Institute of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Research, Stavanger University Hospital, Stavanger, Norway
- Western Norway University of Applied Sciences, Haugesund, Norway
| | - Einar Hannisdal
- Department of health, County Governor in Oslo and Akershus, Oslo, Norway
| | - Kieran Walshe
- The University of Manchester Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Oddbjørn Bukve
- Institute of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
| | | | - Per Stensland
- Department of Global Public Health and Primary Care, Universitetet i Bergen, Bergen, Norway
| | - Jan C Frich
- Institute of Health and Society, Universitetet i Oslo, Oslo, Norway
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Abstract
Locum doctors are often perceived to present greater risks of causing harm to patients than permanent doctors. After eligibility and quality assessment, eight empirical and 34 non-empirical papers were included in a narrative synthesis to establish what was known about the quality and safety of locum medical practice. Empirical literature was limited and weak methodologically. Locums enabled healthcare organisations to maintain appropriate staffing levels and allowed staffing flexibility, but they also gave rise to concerns about continuity of care, patient safety, team function and cost. There was some evidence to suggest that the way locum doctors are recruited, employed and used by organisations, may result in a higher risk of harm to patients. A better understanding of the quality and safety of locum working is needed to improve the use of locum doctors and the quality and safety of patient care that they provide.
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Affiliation(s)
- Jane Ferguson
- Alliance Manchester Business School, The University of Manchester, Manchester M15 6PB, UK
| | - Kieran Walshe
- Alliance Manchester Business School, The University of Manchester, Manchester M15 6PB, UK
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Husabø G, Nilsen RM, Flaatten H, Solligård E, Frich JC, Bondevik GT, Braut GS, Walshe K, Harthug S, Hovlid E. Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study. PLoS One 2020; 15:e0227652. [PMID: 31968009 PMCID: PMC6975530 DOI: 10.1371/journal.pone.0227652] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/22/2019] [Indexed: 12/29/2022] Open
Abstract
Background Early recognition of sepsis is critical for timely initiation of treatment. The first objective of this study was to assess the timeliness of diagnostic procedures for recognizing sepsis in emergency departments. We define diagnostic procedures as tests used to help diagnose the condition of patients. The second objective was to estimate associations between diagnostic procedures and time to antibiotic treatment, and to estimate associations between time to antibiotic treatment and mortality. Methods This observational study from 24 emergency departments in Norway included 1559 patients with infection and at least two systemic inflammatory response syndrome criteria. We estimated associations using linear and logistic regression analyses. Results Of the study patients, 72.9% (CI 70.7–75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (42.4–47.4) were examined by a physician in accordance with the triage priority, 44.4% (41.4–46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (23.2–27.7) received antibiotics within 1 hour. Delay or non-completion of these key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (10.1–17.1), in the timespan 2 to 3 hours after admission 5.9% (2.8–9.1), and 4 hours or later after admission 10.5% (5.7–15.3). Conclusions Key procedures for recognizing sepsis were delayed or not completed in a substantial proportion of patients admitted to the emergency department with sepsis. Delay or non-completion of key diagnostic procedures was associated with prolonged time to treatment with antibiotics. This suggests a need for systematic improvement in the initial management of patients admitted to emergency departments with sepsis.
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Affiliation(s)
- Gunnar Husabø
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- * E-mail:
| | - Roy M. Nilsen
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erik Solligård
- Clinic of Anaesthesia and Intensive Care, St. Olavs Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging and Mid-Norway Sepsis Research Group, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan C. Frich
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Gunnar T. Bondevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Geir S. Braut
- Stavanger University Hospital, Stavanger, Norway
- Norwegian Board of Health Supervision, Oslo, Norway
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, England, United Kingdom
| | - Stig Harthug
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Einar Hovlid
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Norwegian Board of Health Supervision, Oslo, Norway
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Price T, Tredinnick-Rowe J, Walshe K, Tazzyman A, Ferguson J, Boyd A, Archer J, Bryce M. Reviving clinical governance? A qualitative study of the impact of professional regulatory reform on clinical governance in healthcare organisations in England. Health Policy 2020; 124:446-453. [PMID: 32044153 DOI: 10.1016/j.healthpol.2020.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 01/11/2020] [Accepted: 01/15/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Until recently, processes of professional regulation and organisational clinical governance in the UK have been largely separate. However, the introduction of medical revalidation in 2012 means that all doctors have to demonstrate periodically to the regulator that they are up to date and fit to practise, and as part of this process doctors must engage with clinical governance activities in the organisations in which they work. OBJECTIVE To explore how the recent implementation of medical revalidation has affected the arrangements for clinical governance in healthcare organisations in England. DESIGN Thematic analysis of interviews with 62 senior clinicians and non-clinicians in management or senior administrative roles, from a range of healthcare organisations in England. RESULTS Revalidation has engendered changes to clinical governance systems, resulting in: increased doctor engagement with clinical governance activities; new or improved systems for access to clinical governance data for doctors and leaders within healthcare organisations; and more leverage - through the Responsible Officer role - to enforce engagement with clinical governance. Organisational context has been an important mediator of the impact of revalidation on clinical governance. CONCLUSION Revalidation has increased alignment between systems for organisational and professional oversight and accountability, resulting in increased scrutiny of clinical practice. However, it is still a matter of conjecture whether this will in turn lead to improvements in medical performance.
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Affiliation(s)
- Tristan Price
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, PL4 8AA, UK.
| | - John Tredinnick-Rowe
- NIHR Applied Research Collaboration South West Peninsula (PenARC), Faculty of Health: Medicine, Dentistry & Human Sciences, University of Plymouth, Plymouth, PL4 8AA, UK.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, M13 9PL, UK.
| | - Abigail Tazzyman
- School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK.
| | - Jane Ferguson
- Alliance Manchester Business School, University of Manchester, M13 9PL, UK.
| | - Alan Boyd
- Alliance Manchester Business School, University of Manchester, M13 9PL, UK.
| | - Julian Archer
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, PL4 8AA, UK.
| | - Marie Bryce
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, PL4 8AA, UK.
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Tazzyman A, Ferguson J, Boyd A, Bryce M, Tredinnick-Rowe J, Price T, Walshe K. Reforming medical regulation: a qualitative study of the implementation of medical revalidation in England, using Normalization Process Theory. J Health Serv Res Policy 2020; 25:30-40. [PMID: 31112432 PMCID: PMC7307413 DOI: 10.1177/1355819619848017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives The introduction of medical revalidation in 2012 has been a controversial and radical change to medical regulation in the UK. It involved changes to the way organizations manage medical performance, and to the relationships between doctors, their employers and the professional regulatory body. In this paper, we explore the implementation of medical revalidation, analysing the change process and its consequences for doctors and organizations. Methods We conducted a qualitative investigation of the implementation of revalidation in 15 case study organizations in 2016–2017, collecting documents and undertaking a total of 80 interviews with medical and non-medical staff. We used Normalization Process Theory to frame and structure the analysis. Results Revalidation reforms were largely implemented successfully within and across our case study organizations, with evidence of growing acceptance of the purpose and processes of revalidation. There was an emergent shift from securing doctors’ compliance towards the use of revalidation to strengthen clinical governance, and towards evaluating revalidation processes and seeking to make them more effective. However, there was substantial variation in the implementation and impact of revalidation; it was still not fully understood by many doctors, and revalidation processes were highly reliant on a few key individuals in each organization. The changes brought about by revalidation have had consequences for the way in which doctors construct their identity and the way they relate to the organizations in which they work. Conclusion Despite considerable early scepticism and overt opposition in the medical profession, revalidation has become gradually accepted, embedded and even valued over time. Its impact and effectiveness are still questioned by many stakeholders, and the focus of attention has now shifted towards revising and improving the way revalidation works in practice.
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Affiliation(s)
- Abigail Tazzyman
- Research Associate, Alliance Manchester Business School,
University of Manchester, UK
| | - Jane Ferguson
- Research Associate, Alliance Manchester Business School,
University of Manchester, UK
| | - Alan Boyd
- Research Fellow, Alliance Manchester Business School, University
of Manchester, UK
| | | | | | | | - Kieran Walshe
- Professor of Health Policy & Management, Alliance Manchester
Business School, University of Manchester, UK
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Tazzyman A, Bryce M, Ferguson J, Walshe K, Boyd A, Price T, Tredinnick‐Rowe J. Reforming regulatory relationships: The impact of medical revalidation on doctors, employers, and the General Medical Council in the United Kingdom. Regul Gov 2019; 13:593-608. [PMID: 32684944 PMCID: PMC7357781 DOI: 10.1111/rego.12237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/28/2018] [Indexed: 06/11/2023]
Abstract
In 2012, medical regulation in the United Kingdom was fundamentally changed by the introduction of revalidation - a process by which all licensed doctors are required to regularly demonstrate that they are up to date and fit to practice in their chosen field and are able to provide a good level of care. This paper examines the implications of revalidation on the structure, governance, and performance management of the medical profession, as well as how it has changed the relationships between the regulator, employer organizations, and the profession. We conducted semi-structured interviews with clinical and non-clinical staff from a range of healthcare organizations. Our research suggests that organizations have become intermediaries in the relationship between the General Medical Council and doctors, enacting regulatory processes on its behalf and extending regulatory surveillance and oversight at local level. Doctors' autonomy has been reduced as they have become more accountable to and reliant on the organizations that employ them.
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Affiliation(s)
- Abigail Tazzyman
- Alliance Manchester Business School, University of ManchesterManchesterUK
| | | | - Jane Ferguson
- Alliance Manchester Business School, University of ManchesterManchesterUK
| | - Kieran Walshe
- Alliance Manchester Business School, University of ManchesterManchesterUK
| | - Alan Boyd
- Alliance Manchester Business School, University of ManchesterManchesterUK
| | - Tristan Price
- Faculty of Medicine and DentistryPlymouth UniversityPlymouthUK
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Lorne C, McDonald R, Walshe K, Coleman A. Regional assemblage and the spatial reorganisation of health and care: the case of devolution in Greater Manchester, England. Sociol Health Illn 2019; 41:1236-1250. [PMID: 30761548 PMCID: PMC6833925 DOI: 10.1111/1467-9566.12867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In this paper, we examine how space is integral to the practices and politics of restructuring health and care systems and services and specifically how ideas of assemblage can help understand the remaking of a region. We illustrate our arguments by focusing on health and social care devolution in Greater Manchester, England. Emphasising the open-ended political construction of the region, we consider the work of assembling different actors, organisations, policies and resources into a new territorial formation that provisionally holds together without becoming a fixed totality. We highlight how the governing of health and care is shaped through the interplay of local, regional and national actors and organisations coexisting, jostling and forging uneasy alliances. Our goal is to show that national agendas continued to be firmly embedded within the regional project, not least the politics of austerity. Yet through keeping the region together as if it was an integrated whole and by drawing upon new global policy networks, regional actors strategically reworked national agendas in attempts to leverage and compete for new resources and powers. We set out a research agenda that foregrounds how the political reorganisation of health and care is negotiated and contested across multiple spatial dimensions simultaneously.
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Affiliation(s)
- Colin Lorne
- Department of Health Services Research and PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Ruth McDonald
- Alliance Manchester Business SchoolUniversity of ManchesterManchesterUK
| | - Kieran Walshe
- Alliance Manchester Business SchoolUniversity of ManchesterManchesterUK
| | - Anna Coleman
- Centre for Primary CareUniversity of ManchesterManchesterUK
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Furnival J, Boaden R, Walshe K. Assessing improvement capability in healthcare organisations: a qualitative study of healthcare regulatory agencies in the UK. Int J Qual Health Care 2019; 30:715-723. [PMID: 29697843 PMCID: PMC6307330 DOI: 10.1093/intqhc/mzy085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/05/2018] [Indexed: 12/30/2022] Open
Abstract
Objectives Healthcare regulatory agencies are increasingly concerned not just with assessing the current performance of the organisations they regulate, but with assessing their improvement capability to predict their future performance trajectory. This study examines how improvement capability is conceptualised and assessed by healthcare UK regulatory agencies. Design Qualitative analysis of data from six UK healthcare regulatory agencies was conducted. Three data sources were analysed using an a priori framework of eight dimensions of improvement capability identified from an extensive literature review. Setting The focus of the research study was the regulation of hospital-based care, which accounts for the majority of UK healthcare expenditure. Six UK regulatory agencies that review hospital care participated. Participants Data sources included interviews with regulatory staff (n = 48), policy documents (n = 90) and assessment reports (n = 30). Intervention None-this was a qualitative, observational study. Results This research study finds that of eight dimensions of improvement capability, process improvement and learning, and strategy and governance, dominate regulatory assessment practices. The dimension of service-user focus receives the least frequency of use. It may be that dimensions which are relatively easy to 'measure', such as documents for strategy and governance, dominate assessment processes, or there may be gaps in regulatory agencies' assessment instruments, deficits of expertise in improvement capability, or practical difficulties in operationalising regulatory agency intentions to reliably assess improvement capability. Conclusions The UK regulatory agencies seek to assess improvement capability to predict performance trajectories, but out of eight dimensions of improvement capability, two dominate assessment. Furthermore, the definition and meaning of assessment instruments requires development. This would strengthen the validity and reliability of agencies' assessment, diagnosis and prediction of performance trajectories, and support development of more appropriate regulatory performance interventions.
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Affiliation(s)
- Joy Furnival
- Alliance Manchester Business School, Manchester, UK.,NHS Improvement, Wellington House, Waterloo Road, London, UK
| | - Ruth Boaden
- Alliance Manchester Business School, Manchester, UK
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Allen T, Walshe K, Proudlove N, Sutton M. Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England. Emerg Med J 2019; 36:326-332. [PMID: 30944115 PMCID: PMC6582714 DOI: 10.1136/emermed-2018-207941] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 11/25/2022]
Abstract
Introduction Hospital inspection and the publication of inspection ratings are widely used regulatory interventions that may improve hospital performance by providing feedback, creating incentives to change and promoting choice. However, evidence that these interventions assess performance accurately and lead to improved performance is scarce. Methods We calculated six standard indicators of emergency department (ED) performance for 118 hospitals in England whose EDs were inspected by the Care Quality Commission, the national regulator in England, between 2013 and 2016. We linked these to inspection dates and subsequent rating scores. We used multilevel linear regression models to estimate the relationship between prior performance and subsequent rating score and the relationship between rating score and post-inspection performance. Results We found no relationship between performance on any of the six indicators prior to inspection and the subsequent rating score. There was no change in performance on any of the six indicators following inspection for any rating score. In each model, CIs were wide indicating no statistically significant relationships. Discussion We found no association between established performance indicators and rating scores. This might be because the inspection and rating process adds little to the external performance management that EDs receive. It could also indicate the limited ability of hospitals to improve ED performance because of extrinsic factors that are beyond their control.
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Affiliation(s)
- Thomas Allen
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Nathan Proudlove
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Matt Sutton
- School of Health Sciences, University of Manchester, Manchester, UK
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Gutacker N, Bloor K, Bojke C, Archer J, Walshe K. Does regulation increase the rate at which doctors leave practice? Analysis of routine hospital data in the English NHS following the introduction of medical revalidation. BMC Med 2019; 17:33. [PMID: 30744639 PMCID: PMC6371486 DOI: 10.1186/s12916-019-1270-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/22/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In 2012, the UK introduced medical revalidation, whereby to retain their licence all doctors are required to show periodically that they are up to date and fit to practise medicine. Early reports suggested that some doctors found the process overly onerous and chose to leave practice. This study investigates the effect of medical revalidation on the rate at which consultants (senior hospital doctors) leave NHS practice, and assesses any differences between the performance of consultants who left or remained in practice before and after the introduction of revalidation. METHODS We used a retrospective cohort of administrative data from the Hospital Episode Statistics database on all consultants who were working in English NHS hospitals between April 2008 and March 2009 (n = 19,334), followed to March 2015. Proportional hazard models were used to identify the effect of medical revalidation on the time to exit from the NHS workforce, as implied by ceasing NHS clinical activity. The main exposure variable was consultants' time-varying revalidation status, which differentiates between periods when consultants were (a) not subject to revalidation-before the policy was introduced, (b) awaiting a revalidation recommendation and (c) had received a positive recommendation to be revalidated. Difference-in-differences analysis was used to compare the performance of those who left practice with those who remained in practice before and after the introduction of revalidation, as proxied by case-mix-adjusted 30-day mortality rates. RESULTS After 2012, consultants who had not yet revalidated were at an increased hazard of ceasing NHS clinical practice (HR 2.33, 95% CI 2.12 to 2.57) compared with pre-policy levels. This higher risk remained after a positive recommendation (HR 1.85, 95% CI 1.65 to 2.06) but was statistically significantly reduced (p < 0.001). We found no statistically significant differences in mortality rates between those consultants who ceased practice and those who remained, after adjustment for multiple testing. CONCLUSION Revalidation appears to have led to greater numbers of doctors ceasing clinical practice, over and above other contemporaneous influences. Those ceasing clinical practice do not appear to have provided lower quality care, as approximated by mortality rates, when compared with those remaining in practice.
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Affiliation(s)
- Nils Gutacker
- Centre for Health Economics, University of York, York, UK.
| | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
| | - Chris Bojke
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julian Archer
- Collaboration for the Advancement of Medical Education Research Assessment, University of Plymouth, Plymouth, UK
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK
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Richardson E, Walshe K, Boyd A, Roberts J, Wenzel L, Robertson R, Smithson R. User involvement in regulation: A qualitative study of service user involvement in Care Quality Commission inspections of health and social care providers in England. Health Expect 2018; 22:245-253. [PMID: 30525272 PMCID: PMC6433317 DOI: 10.1111/hex.12849] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/19/2018] [Accepted: 10/23/2018] [Indexed: 11/28/2022] Open
Abstract
Background High profile failures of care in the NHS have raised concerns about regulatory systems for health‐care professionals and organizations. In response, the Care Quality Commission (CQC), the regulator of health and social care in England overhauled its regulatory regime. It moved to inspections which made much greater use of expert knowledge, data and views from a range of stakeholders, including service users. Objective We explore the role of service users and citizens in health and social care regulation, including how CQC involved people in inspecting and rating health and social care providers. Design We analyse CQC reports and documents, and 61 interviews with CQC staff and representatives of groups of service users and citizens and voluntary sector organizations to explore the place of service user voice in regulatory processes. Results Care Quality Commission invited comments and facilitated the sharing of existing service user experiences and engaged with representatives of groups of service users and voluntary sector organizations. CQC involved service users in their inspections as “experts by experience.” Information from service users informed both the inspection regime and individual inspections, but CQC was less focused on giving feedback to service users who contributed to these activities. Discussion and conclusions Service users can make an important contribution to regulation by sharing their experiences and having their voices heard, but their involvement was somewhat transactional, and largely on terms set by CQC. There may be scope for CQC to build more enduring relationships with service user groups and to engage them more effectively in the regulatory regime.
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Affiliation(s)
- Emma Richardson
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Alan Boyd
- Alliance Manchester Business School, University of Manchester, Manchester, UK
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Darley S, Walshe K, Boaden R, Proudlove N, Goff M. Improvement capability and performance: a qualitative study of maternity services providers in the UK. Int J Qual Health Care 2018; 30:692-700. [PMID: 29669040 PMCID: PMC6307332 DOI: 10.1093/intqhc/mzy081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/13/2018] [Accepted: 04/03/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We explore variations in service performance and quality improvement across healthcare organisations using the concept of improvement capability. We draw upon a theoretically informed framework comprising eight dimensions of improvement capability, firstly to describe and compare quality improvement within healthcare organisations and, secondly to investigate the interactions between organisational performance and improvement capability. DESIGN A multiple qualitative case study using semi-structured interviews guided by the improvement capability framework. SETTING Five National Health Service maternity services sites across the UK. We focused on maternity services due to high levels of variation in quality and the availability of performance metrics which enabled us to select organisations from across the performance spectrum. PARTICIPANTS About 52 hospital staff members across the five case studies in positions relevant to the research questions, including midwives, obstetricians and clinical managers/leaders. MAIN OUTCOME MEASURE A qualitative analysis of narratives of quality improvement and performance in the five case studies, using the improvement capability framework as an analytic device to compare and contrast cases. RESULTS The improvement capability framework has utility in analysing quality improvement within and across organisations. Qualitative differences in the configurations of improvement capability were identified across all providers but were particularly striking between higher and lower performing organisations. CONCLUSIONS The improvement capability framework is a useful tool for healthcare organisations to assess, manage and develop their own improvement capabilities. We identified an interaction between performance and improvement capability; higher performing organisations appeared to have more developed improvement capabilities, though the meaning of this relationship requires further research.
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Affiliation(s)
- Sarah Darley
- Centre for Primary Care, School of Health Sciences, Oxford Road, Manchester, UK
| | - Kieran Walshe
- Health Management Group, Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Ruth Boaden
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Alliance Manchester Business School, Booth Street West, Manchester, UK
| | - Nathan Proudlove
- Health Management Group, Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Mhorag Goff
- Health Services Research Centre, Alliance Manchester Business School, University of Manchester, Manchester, UK
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Bryce M, Luscombe K, Boyd A, Tazzyman A, Tredinnick-Rowe J, Walshe K, Archer J. Policing the profession? Regulatory reform, restratification and the emergence of Responsible Officers as a new locus of power in UK medicine. Soc Sci Med 2018; 213:98-105. [PMID: 30064094 PMCID: PMC6137071 DOI: 10.1016/j.socscimed.2018.07.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 11/26/2022]
Abstract
Doctors' work and the changing, contested meanings of medical professionalism have long been a focus for sociological research. Much recent attention has focused on those doctors working at the interface between healthcare management and medical practice, with such ‘hybrid’ doctor-managers providing valuable analytical material for exploring changes in how medical professionalism is understood. In the United Kingdom, significant structural changes to medical regulation, most notably the introduction of revalidation in 2012, have created a new hybrid group, Responsible Officers (ROs), responsible for making periodic recommendations about the on-going fitness to practise medicine of all other doctors in their organisation. Using qualitative data collected in a 2015 survey with 374 respondents, 63% of ROs in the UK, this paper analyses the RO role. Our findings show ROs to be a distinct emergent group of hybrid professionals and as such demonstrate restructuring within UK medicine. Occupying a position where multiple agendas converge, ROs' work expands professional regulation into the organisational sphere in new ways, as well as creating new lines of continuous accountability between the wider profession and the General Medical Council as medical regulator. Our exploration of ROs' approaches to their work offers new insights into the on-going development of medical professionalism, pointing to the emergence of a distinctly regulatory hybrid professionalism shaped by co-existing professional, managerial and regulatory logics, in an era of strengthened governance and complex policy change. Responsible Officers are a new governance elite group in the UK medical profession. They work at the nexus of professional, managerial and regulatory spheres. Differ from other doctor-managers due to accountability for medical performance. Organisational context shapes experiences of this new role. Regulatory reform has engendered a new form of hybrid professionalism.
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Affiliation(s)
- Marie Bryce
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Kayleigh Luscombe
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Alan Boyd
- Alliance Manchester Business School, University of Manchester, Manchester, UK.
| | - Abigail Tazzyman
- Alliance Manchester Business School, University of Manchester, Manchester, UK.
| | - John Tredinnick-Rowe
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK.
| | - Julian Archer
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.
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Ulph F, Wright S, Dharni N, Payne K, Bennett R, Roberts S, Walshe K, Lavender T. Provision of information about newborn screening antenatally: a sequential exploratory mixed-methods project. Health Technol Assess 2018; 21:1-240. [PMID: 28967862 DOI: 10.3310/hta21550] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Participation in the UK Newborn Bloodspot Screening Programme (NBSP) requires parental consent but concerns exist about whether or not this happens in practice and the best methods and timing to obtain consent at reasonable cost. OBJECTIVES To collate all possible modes of prescreening communication and consent for newborn (neonatal) screening (NBS); examine midwives', screening professionals' and users' views about the feasibility, efficiency and impact on understanding of each; measure midwives' and parents' preferences for information provision; and identify key drivers of cost-effectiveness for alternative modes of information provision. DESIGN Six study designs were used: (1) realist review - to generate alternative communication and consent models; (2) qualitative interviews with parents and health professionals - to examine the implications of current practice for understanding and views on alternative models; (3) survey and observation of midwives - to establish current costs; (4) stated preference surveys with midwives, parents and potential future parents - to establish preferences for information provision; (5) economic analysis - to identify cost-effectiveness drivers of alternative models; and (6) stakeholder validation focus groups and interviews - to examine the acceptability, views and broader impact of alternative communication and consent models. SETTING Providers and users of NBS in England. PARTICIPANTS Study 2: 45 parents and 37 health professionals; study 3: 22 midwives and eight observations; study 4: 705 adults aged 18-45 years and 134 midwives; and study 6: 12 health-care professionals and five parents. RESULTS The realist review identified low parental knowledge and evidence of coercive consent practices. Interview, focus group and stated preference data suggested a preference for full information, with some valuing this more than choice. Health professionals preferred informed choice models but parents and health professionals queried whether or not current consent was fully informed. Barriers to using leaflets effectively were highlighted. All studies indicated that a 'personalised' approach to NBS communication, allowing parents to select the mode and level of information suited to their learning needs, could have added value. A personalised approach should rely on midwife communication and should occur in the third trimester. Overall awareness was identified as requiring improvement. Starting NBS communication by alerting parents that they have a choice to make and telling them that samples could be stored are both likely to enhance engagement. The methods of information provision and maternal anxiety causing additional visits to health-care professionals were the drivers of relative cost-effectiveness. Lack of data to populate an economic analysis, confirmed by value of information analysis, indicated a need for further research. LIMITATIONS There are some limitations with regard to the range of participants used in studies 2 and 3 and so caution should be exercised when interpreting some of the results. CONCLUSIONS This project highlighted the importance of focusing on information receipt and identified key communication barriers. Health professionals strongly preferred informed consent, which parents endorsed if they were made aware of sample storage. Uniform models of information provision were perceived as ineffective. A choice of information provision was supported by health professionals and parents, which both enhances cost-effectiveness and improves engagement, understanding and the validity of consent. Remaining uncertainties suggest that more research is needed before new communication modes are introduced into practice. Future research should measure the impact of the suggested practice changes (informing in third trimester, information toolkits, changed role of midwife). TRIAL REGISTRATION Current Controlled Trials ISRCTN70227207. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 55. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fiona Ulph
- Division of Mental Health and Psychology, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stuart Wright
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Nimarta Dharni
- Division of Mental Health and Psychology, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Katherine Payne
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Stephen Roberts
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Tina Lavender
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Affiliation(s)
- Kieran Walshe
- Alliance Manchester Business School, University of Manchester, UK
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33
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Furnival J, Boaden R, Walshe K. Conceptualizing and assessing improvement capability: a review. Int J Qual Health Care 2018; 29:604-611. [PMID: 28992146 PMCID: PMC5890875 DOI: 10.1093/intqhc/mzx088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 07/05/2017] [Indexed: 12/31/2022] Open
Abstract
Purpose The literature is reviewed to examine how ‘improvement capability’ is conceptualized and assessed and to identify future areas for research. Data sources An iterative and systematic search of the literature was carried out across all sectors including healthcare. The search was limited to literature written in English. Data extraction The study identifies and analyses 70 instruments and frameworks for assessing or measuring improvement capability. Information about the source of the instruments, the sectors in which they were developed or used, the measurement constructs or domains they employ, and how they were tested was extracted. Results of data synthesis The instruments and framework constructs are very heterogeneous, demonstrating the ambiguity of improvement capability as a concept, and the difficulties involved in its operationalisation. Two-thirds of the instruments and frameworks have been subject to tests of reliability and half to tests of validity. Many instruments have little apparent theoretical basis and do not seem to have been used widely. Conclusion The assessment and development of improvement capability needs clearer and more consistent conceptual and terminological definition, used consistently across disciplines and sectors. There is scope to learn from existing instruments and frameworks, and this study proposes a synthetic framework of eight dimensions of improvement capability. Future instruments need robust testing for reliability and validity. This study contributes to practice and research by presenting the first review of the literature on improvement capability across all sectors including healthcare.
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Affiliation(s)
- Joy Furnival
- Improvement Directorate, 133-155 Waterloo Rd, Lambeth, London SE1 8UG, UK
| | - Ruth Boaden
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Alliance Manchester Business School, Booth Street West, Manchester M15 6PB, UK
| | - Kieran Walshe
- Health Management Group, Alliance Manchester Business School, Booth Street West, Manchester M15 6PB, UK
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Gutacker N, Bloor K, Bojke C, Walshe K. Should interventions to reduce variation in care quality target doctors or hospitals? Health Policy 2018; 122:660-666. [PMID: 29703654 PMCID: PMC6022214 DOI: 10.1016/j.healthpol.2018.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 10/16/2017] [Accepted: 04/06/2018] [Indexed: 11/29/2022]
Abstract
Performance management initiatives are increasingly targeting individual doctors as well as hospitals. Less than 25% of variation in clinical outcomes is attributable to providers. More variation in clinical outcomes is associated with doctors than with hospitals. Performance estimates for individual doctors are unreliable due to small samples.
Interventions to reduce variation in care quality are increasingly targeted at both individual doctors and the organisations in which they work. Concerns remain about the scope and consequences for such performance management, the relative contribution of individuals and organisations to observed variation, and whether performance can be measured reliably. This study explores these issues in the context of the English National Health Service by analysing comprehensive administrative data for all patients treated for four clinical conditions (acute myocardial infarction, hip fracture, pneumonia, ischemic stroke) and two surgical procedures (coronary artery bypass, hip replacement) during April 2010–February 2013. Performance indicators are defined as 30-day mortality, 28-day emergency readmission and inpatient length of stay. Three-level hierarchical generalised linear mixed models are estimated to attribute variation in case-mix adjusted indicators to individual doctors and hospital organisations. Except for length of stay after hip replacement, no more than 11% of variation in case-mix adjusted performance indicators can be attributed to doctors and organisations with the rest reflecting random chance and unobserved patient factors. Doctor variation exceeds hospital variation by a factor of 1.2 or more. However, identifying poor performance amongst doctors is hampered by insufficient numbers of cases per doctor to reliably estimate their individual performances. Policy makers and regulators should therefore be cautious when targeting individual doctors in performance improvement initiatives.
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Affiliation(s)
- Nils Gutacker
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - Karen Bloor
- Department of Health Sciences, University of York, United Kingdom.
| | - Chris Bojke
- Centre for Health Economics, University of York, United Kingdom.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, United Kingdom.
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35
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Tazzyman A, Ferguson J, Walshe K, Boyd A, Tredinnick-Rowe J, Hillier C, Regan De Bere S, Archer J. The Evolving Purposes of Medical Revalidation in the United Kingdom: A Qualitative Study of Professional and Regulatory Narratives. Acad Med 2018; 93:642-647. [PMID: 29116977 PMCID: PMC5895134 DOI: 10.1097/acm.0000000000001993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
PURPOSE Previous research found professionalism and regulation to be competing discourses when plans for medical revalidation in the United Kingdom were being developed in 2011. The purpose of this study was to explore how these competing discourses developed and how the perceived purposes of revalidation evolved as the policy was implemented. METHOD Seventy-one interviews with 60 UK policy makers and senior health care leaders were conducted during the development and implementation of revalidation: 31 in 2011, 26 in 2013, and 14 in 2015. Interviewees were selected using purposeful sampling. Across all interviews, questions focused around three areas: individual roles in relation to revalidation; interviewees' understanding of revalidation, its purpose, and aims; and predictions or experiences of revalidation's impact. The first two interview sets also included questions about measurement and evaluation of revalidation. Data were analyzed using the constant comparative method to understand changes and continuities. RESULTS Two main discourses regarding the purpose of revalidation were present across the implementation period: professionalism and regulation. The nature of the relationship between these two purposes and how they were described changed over time, with the separate discourses converging, and early concerns about actual or potential conflict being replaced by perceptions of coexistence or codependency. CONCLUSIONS The changing nature of the discourse about revalidation suggests that early concerns about adverse consequences were not borne out as organizations and professionals engaged with implementation and experienced the realities of revalidation in practice. Reconciling professional and regulatory narratives was arguably necessary to the effective implementation of revalidation.
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Affiliation(s)
- Abigail Tazzyman
- 1A. Tazzyman is research associate, Alliance Manchester Business School, University of Manchester, Manchester, England
| | - Jane Ferguson
- 2J. Ferguson is research associate, Alliance Manchester Business School, University of Manchester, Manchester, England
| | - Kieran Walshe
- 3K. Walshe is professor of health policy and management, Alliance Manchester Business School, University of Manchester, Manchester, England
| | - Alan Boyd
- 4A. Boyd is research fellow, Alliance Manchester Business School, University of Manchester, Manchester, England
| | - John Tredinnick-Rowe
- 5J. Tredinnick-Rowe is research assistant, Plymouth University, Plymouth, England
| | - Charlotte Hillier
- 6C. Hillier was research associate, Alliance Manchester Business School, University of Manchester, Manchester, England
| | | | - Julian Archer
- 8J. Archer is senior clinical lecturer and director, Collaboration for the Advancement in Medical Education Research and Assessment, Plymouth University, Plymouth, England
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Abstract
Purpose The purpose of this paper is to understand how inspection team members work together to conduct surveys of hospitals, the challenges teams may face and how these might be addressed. Design/methodology/approach Data were gathered through an evaluation of a new regulatory model for acute hospitals in England, implemented by the Care Quality Commission (CQC) during 2013-2014. The authors interviewed key stakeholders, observed inspections and surveyed and interviewed inspection team members and hospital staff. Common characteristics of temporary teams provided an analytical framework. Findings The temporary nature of the inspection teams hindered the conduct of some inspection activities, despite the presence of organisational citizenship behaviours. In a minority of sub-teams, there were tensions between CQC employed inspectors, healthcare professionals, lay people and CQC data analysts. Membership changes were infrequent and did not appear to inhibit team functioning, with members displaying high commitment. Although there were leadership authority ambiguities, these were not problematic. Existing processes of recruitment and selection, training and preparation and to some extent leadership, did not particularly lend themselves to addressing the challenges arising from the temporary nature of the teams. Research limitations/implications Conducting the research during the piloting of the new regulatory approach may have accentuated some challenges. There is scope for further research on inspection team leadership. Practical implications Issues may arise if inspection and accreditation agencies deploy temporary, heterogeneous survey teams. Originality/value This research is the first to illuminate the functioning of inspection survey teams by applying a temporary teams perspective.
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Affiliation(s)
- Alan Boyd
- Alliance Manchester Business School, University of Manchester , Manchester, UK
| | | | | | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester , Manchester, UK
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Proudlove NC, Samarasinghe BS, Walshe K. Investigating consistent patterns of variation in short-notice cancellations of elective operations: The potential for learning and improvement through multi-site evaluations. Health Serv Manage Res 2017; 31:111-119. [PMID: 29256264 DOI: 10.1177/0951484817745064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
As part of efforts to increase productivity in healthcare, there is considerable interest in the extent and causes of variation in the performance of provider organisations. In this study, we use publically available data from the English NHS to examine the characteristics of variation in the rates of short-notice cancellations of elective operations due to hospital reasons (e.g. lack of the required resources such as operating theatres and beds). We find that the variation between hospital trusts is very non-random. There is a fourfold difference in the cancellation rates between the top and bottom deciles of performance. Little is known about the causes of this. There is a large and striking consistency in the relative performance of hospital trusts on cancellation rates over the last five years. Thus, the best and worst performers are consistently relatively very good or very poor, so a multi-site comparison of practices, and accounting for confounds like patient demographics, could be very valuable to inform both this knowledge gap and practice in healthcare. Of particular interest is that the cancellation rates could be a symptom of deeper issues with the efficiency of patient flows within hospitals.
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Affiliation(s)
- Nathan C Proudlove
- 1 Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Kieran Walshe
- 1 Alliance Manchester Business School, University of Manchester, Manchester, UK
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Tazzyman A, Ferguson J, Hillier C, Boyd A, Tredinnick-Rowe J, Archer J, de Bere SR, Walshe K. The implementation of medical revalidation: an assessment using normalisation process theory. BMC Health Serv Res 2017; 17:749. [PMID: 29157254 PMCID: PMC5697083 DOI: 10.1186/s12913-017-2710-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 11/07/2017] [Indexed: 11/21/2022] Open
Abstract
Background Medical revalidation is the process by which all licensed doctors are legally required to demonstrate that they are up to date and fit to practise in order to maintain their licence. Revalidation was introduced in the United Kingdom (UK) in 2012, constituting significant change in the regulation of doctors. The governing body, the General Medical Council (GMC), envisages that revalidation will improve patient care and safety. This potential however is, in part, dependent upon how successfully revalidation is embedded into routine practice. The aim of this study was to use Normalisation Process Theory (NPT) to explore issues contributing to or impeding the implementation of revalidation in practice. Methods We conducted seventy-one interviews with sixty UK policymakers and senior leaders at different points during the development and implementation of revalidation: in 2011 (n = 31), 2013 (n = 26) and 2015 (n = 14). We selected interviewees using purposeful sampling. NPT was used as a framework to enable systematic analysis across the interview sets. Results Initial lack of consensus over revalidation’s purpose, and scepticism about its value, decreased over time as participants recognised the benefits it brought to their practice (coherence category of NPT). Though acceptance increased across time, revalidation was not seen as a legitimate part of their role by all doctors. Key individuals, notably the Responsible Officer (RO), were vital for the successful implementation of revalidation in organisations (cognitive participation category). The ease with which revalidation could be integrated into working practices varied greatly depending on the type of role a doctor held and the organisation they work for and the provision of resources was a significant variable in this (collective action category). Formal evaluation of revalidation in organisations was lacking but informal evaluation was taking place. Revalidation had not yet reached the stage where feedback was being used for improvement (reflexive monitoring category). Conclusions Requiring all organisations to use the same revalidation model made revalidation easy to integrate into existing work for some but problematic for others. In order for revalidation to be fully embedded and successful, impeding factors, such as a lack of resources, need to be addressed.
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Affiliation(s)
- Abigail Tazzyman
- Alliance Manchester Business School, The University of Manchester, Booth Street East, Manchester, M13 9SS, UK.
| | - Jane Ferguson
- Alliance Manchester Business School, The University of Manchester, Booth Street East, Manchester, M13 9SS, UK
| | - Charlotte Hillier
- Alliance Manchester Business School, The University of Manchester, Booth Street East, Manchester, M13 9SS, UK.,Plymouth University, Drake Circus, Plymouth, Devon, PL4 8AA, UK
| | - Alan Boyd
- Alliance Manchester Business School, The University of Manchester, Booth Street East, Manchester, M13 9SS, UK
| | | | - Julian Archer
- Plymouth University, Drake Circus, Plymouth, Devon, PL4 8AA, UK
| | | | - Kieran Walshe
- Alliance Manchester Business School, The University of Manchester, Booth Street East, Manchester, M13 9SS, UK
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Hovlid E, Frich JC, Walshe K, Nilsen RM, Flaatten HK, Braut GS, Helgeland J, Teig IL, Harthug S. Effects of external inspection on sepsis detection and treatment: a study protocol for a quasiexperimental study with a stepped-wedge design. BMJ Open 2017; 7:e016213. [PMID: 28877944 PMCID: PMC5589010 DOI: 10.1136/bmjopen-2017-016213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Inspections are widely used in health care as a means to improve the health services delivered to patients. Despite their widespread use, there is little evidence of their effect. The mechanisms for how inspections can promote change are poorly understood. In this study, we use a national inspection campaign of sepsis detection and initial treatment in hospitals as case to: (1) Explore how inspections affect the involved organizations. (2) Evaluate what effect external inspections have on the process of delivering care to patients, measured by change in indicators reflecting how sepsis detection and treatment is carried out. (3) Evaluate whether external inspections affect patient outcomes, measured as change in the 30-day mortality rate and length of hospital stay. METHODS AND ANALYSIS The intervention that we study is inspections of sepsis detection and treatment in hospitals. The intervention will be rolled out sequentially during 12 months to 24 hospitals. Our effect measures are change on indicators related to the detection and treatment of sepsis, the 30-day mortality rate and length of hospital stay. We collect data from patient records at baseline, before the inspections, and at 8 and 14 months after the inspections. We use logistic regression models and linear regression models to compare the various effect measurements between the intervention and control periods. All the models will include time as a covariate to adjust for potential secular changes in the effect measurements during the study period. We collect qualitative data before and after the inspections, and we will conduct a thematic content analysis to explore how inspections affect the involved organisations. ETHICS AND DISSEMINATION The study has obtained ethical approval by the Regional Ethics Committee of Norway Nord and the Norwegian Data Protection Authority. It is registered at www.clinicaltrials.gov (Identifier: NCT02747121). Results will be reported in international peer-reviewed journals. TRIAL REGISTRATION NCT02747121; Pre-results.
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Affiliation(s)
- Einar Hovlid
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal and Norwegian Board of Health Supervision, Oslo, Norway
| | - Jan C Frich
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kieran Walshe
- Health Management Group, Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Roy M Nilsen
- Department of Health and Social Sciences, Department of Research and Development, Western Norway University of Applied Sciences, Haukeland University Hospital, Bergen, Norway
| | - Hans Kristian Flaatten
- Department of Anaesthesia and Intensive Care, Department of Clinical Medicine, Haukeland University Hospital, University of Bergen, Bergen, Norway
| | - Geir Sverre Braut
- Department of research, Stavanger University Hospital, Stavanger; Norwegian Board of Health Supervision, Oslo, Norway
| | - Jon Helgeland
- Quality Measurement Unit, Norwegian Institute of Public Health, Oslo, Norway
| | - Inger Lise Teig
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Stig Harthug
- Department of Research and Development, Department of Clinical Science, Faculty of Medicine and Dentistry, Haukeland University Hospital, University of Bergen, Bergen, Norway
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Furnival JF, Walshe K, Boaden R. ISQUA17-1226REGULATORY CONCEPTUALISATION AND ASSESSMENT OF HEALTHCARE IMPROVEMENT CAPABILITY IN THE UK. Int J Qual Health Care 2017. [DOI: 10.1093/intqhc/mzx125.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Purpose Healthcare regulation is one means to address quality challenges in healthcare systems and is carried out using compliance, deterrence and/or improvement approaches. The four countries of the UK provide an opportunity to explore and compare different regulatory architecture and models. The purpose of this paper is to understand emerging regulatory models and associated tensions. Design/methodology/approach This paper uses qualitative methods to compare the regulatory architecture and models. Data were collected from documents, including board papers, inspection guidelines and from 48 interviewees representing a cross-section of roles from six organisational regulatory agencies. The data were analysed thematically using an a priori coding framework developed from the literature. Findings The findings show that regulatory agencies in the four countries of the UK have different approaches and methods of delivering their missions. This study finds that new hybrid regulatory models are developing which use improvement support interventions in parallel with deterrence and compliance approaches. The analysis highlights that effective regulatory oversight of quality is contingent on the ability of regulatory agencies to balance their requirements to assure and improve care. Nevertheless, they face common tensions in sustaining the balance in their requirements connected to their roles, relationships and resources. Originality/value The paper shows through its comparison of UK regulatory agencies that the development and implementation of hybrid models is complex. The paper contributes to research by identifying three tensions related to hybrid regulatory models; roles, resources and relationships which need to be managed to sustain hybrid regulatory models.
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Affiliation(s)
- Joy Furnival
- Health Management Group, Alliance Manchester Business School, University of Manchester , Manchester, UK
| | - Kieran Walshe
- Health Management Group, Alliance Manchester Business School, University of Manchester , Manchester, UK
| | - Ruth Boaden
- Collaboration for Leadership in Applied Health Research and Care Greater Manchester, Alliance Manchester Business School, University of Manchester , Manchester, UK
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Affiliation(s)
- Kieran Walshe
- Alliance Manchester Business School, University of Manchester, UK
- Correspondence to: K Walshe
| | - Naomi Chambers
- Alliance Manchester Business School, University of Manchester, UK
- Correspondence to: K Walshe
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Walshe K, Boyd A, Bryce M, Luscombe K, Tazzyman A, Tredinnick-Rowe J, Archer J. Implementing medical revalidation in the United Kingdom: Findings about organisational changes and impacts from a survey of Responsible Officers. J R Soc Med 2017; 110:23-30. [PMID: 28084166 PMCID: PMC5298426 DOI: 10.1177/0141076816683556] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To describe the implementation of medical revalidation in healthcare organisations in the United Kingdom and to examine reported changes and impacts on the quality of care. Design A cross-sectional online survey gathering both quantitative and qualitative data about structures and processes for medical revalidation and wider quality management in the organisations which employ or contract with doctors (termed 'designated bodies') from the senior doctor in each organisation with statutory responsibility for medical revalidation (termed the 'Responsible Officer'). Setting United Kingdom Participants Responsible Officers in designated bodies in the United Kingdom. Five hundred and ninety-five survey invitations were sent and 374 completed surveys were returned (63%). Main outcome measures The role of Responsible Officers, the development of organisational mechanisms for quality assurance or improvement, decision-making on revalidation recommendations, impact of revalidation and mechanisms for quality assurance or improvement on clinical practice and suggested improvements to revalidation arrangements. Results Responsible Officers report that revalidation has had some impacts on the way medical performance is assured and improved, particularly strengthening appraisal and oversight of quality within organisations and having some impact on clinical practice. They suggest changes to make revalidation less 'one size fits all' and more responsive to individual, organisational and professional contexts. Conclusions Revalidation appears primarily to have improved systems for quality improvement and the management of poor performance to date. There is more to be done to ensure it produces wider benefits, particularly in relation to doctors who already perform well.
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Affiliation(s)
- Kieran Walshe
- 1 Alliance Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Alan Boyd
- 1 Alliance Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Marie Bryce
- 2 Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Plymouth University Peninsula Schools of Medicine & Dentistry, Plymouth PL4 8AA, UK
| | - Kayleigh Luscombe
- 2 Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Plymouth University Peninsula Schools of Medicine & Dentistry, Plymouth PL4 8AA, UK
| | - Abigail Tazzyman
- 1 Alliance Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - John Tredinnick-Rowe
- 2 Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Plymouth University Peninsula Schools of Medicine & Dentistry, Plymouth PL4 8AA, UK
| | - Julian Archer
- 2 Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Plymouth University Peninsula Schools of Medicine & Dentistry, Plymouth PL4 8AA, UK
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Abstract
The credibility of a regulator could be threatened if stakeholders perceive that assessments of performance made by its inspectors are unreliable. Yet there is little published research on the reliability of inspectors’ assessments of health care organizations’ services.
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Affiliation(s)
- Alan Boyd
- 1 Research Fellow in Healthcare and Public Sector Management, Alliance Manchester Business School, University of Manchester, UK
| | | | | | | | - Kieran Walshe
- 5 Professor of Health Policy and Management, Alliance Manchester Business School, University of Manchester, UK
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Abstract
Social regulation is ubiquitous in the US healthcare system, and American healthcare organizations claim to be among the most regulated institutions in the world. Yet relatively little is known about the impact of social regulation on these organizations' performance, or about the characteristics or determinants of effective regulatory strategies and approaches. This paper explores the use of social regulation in US healthcare, drawing on the wider literature on regulation in other countries and settings and on the growing body of general regulatory theory. It offers a framework for analysing and comparing regulatory arrangements, presents the findings from an exploratory qualitative study of regulators and regulated organizations, and concludes by developing a framework of the emergent characteristics of effective regulation which might be used in future evaluations of healthcare regulation.
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Ireri SK, Walshe K, Benson L, Mwanthi M. A comparison of experiences, competencies and development needs of doctor managers in Kenya and the United Kingdom (UK). Int J Health Plann Manage 2016; 32:509-539. [PMID: 27139581 DOI: 10.1002/hpm.2357] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 02/16/2016] [Accepted: 03/31/2016] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The purpose of the research was to explore and compare the experiences, leadership and management competencies and development needs of doctor managers in Kenya and the UK. DESIGN/METHODOLOGY A comparative study d258esign involving fieldwork in Kenya and the UK was adopted. Data were collected using a multi-method approach: qualitative interviews and a survey with doctor managers. The template method was used for qualitative data analysis while appropriate statistical tests in SPSS were used for quantitative data analysis. FINDINGS The findings of the study add to the knowledge on experiences of doctor managers, competencies and development needs. Ways of addressing some of the difficulties are proposed. RESEARCH LIMITATIONS/IMPLICATIONS The study highlights issues of a comparative study across different cultures and the issue of bias that is associated with self reports. PRACTICAL AND SOCIAL IMPLICATIONS It is assumed that management decisions have much in common and the training and socialisation of doctors as professionals is somewhat similar. This paper explores if there are any experiences that are transferable and if competency frameworks in healthcare used in developed countries are transferable to a developing country. ORIGINALITY/VALUE The study gives baseline knowledge and insight into the experiences, competencies and development needs of doctor managers in a developing country and adds to existing knowledge on doctor managers in the UK. This study has also provided currently the only international study comparing the experiences, competencies and development needs of doctors in management.
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Affiliation(s)
| | | | | | - Mutuku Mwanthi
- School of Public Health, University of Nairobi, Nairobi, Kenya
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48
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Affiliation(s)
- Kieran Walshe
- Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Anna Coleman
- Centre for Primary Care, University of Manchester
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Colin Lorne
- Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Luke Munford
- Centre for Health Economics, University of Manchester
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Abstract
Healthcare practitioners' fitness to practise has often been linked to their personal and demographic characteristics. It is possible that situational factors, such as the work environment and physical or psychological well-being, also have an influence on an individual's fitness to practise. However, it is unclear how these factors might be linked to behaviours that risk compromising fitness to practise. The aim of this study was to examine the association between job characteristics, well-being and behaviour reflecting risky practice amongst a sample of registered pharmacists in a region of the United Kingdom. Data were obtained from a cross-sectional self-report survey of 517 pharmacists. These data were subjected to principal component analysis and path analysis, with job characteristics (demand, autonomy and feedback) and well-being (distress and perceived competence) as the predictors and behaviour as the outcome variable. Two aspects of behaviour were found: Overloading (taking on more work than one can comfortably manage) and risk taking (working at or beyond boundaries of safe practice). Separate path models including either job characteristics or well-being as independent variables provided a good fit to the data-set. Of the job characteristics, demand had the strongest association with behaviour, while the association between well-being and risky behaviour differed according to the aspect of behaviour being assessed. The findings suggest that, in general terms, situational factors should be considered alongside personal factors when assessing, judging or remediating fitness to practise. They also suggest the presence of different facets to the relationship between job characteristics, well-being and risky behaviour amongst pharmacists.
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Affiliation(s)
- Denham L Phipps
- a Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School , The University of Manchester , Manchester , UK.,b NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre , Manchester , UK
| | - Kieran Walshe
- c Manchester Business School , The University of Manchester , Manchester , UK
| | - Dianne Parker
- a Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School , The University of Manchester , Manchester , UK.,b NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre , Manchester , UK
| | - Peter R Noyce
- a Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School , The University of Manchester , Manchester , UK
| | - Darren M Ashcroft
- a Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School , The University of Manchester , Manchester , UK.,b NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre , Manchester , UK
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50
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Affiliation(s)
- Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester M15 6PB, UK
| | - Judith Smith
- Health Services Management Centre, University of Birmingham, Birmingham, UK
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