English National Research Articles

Are we delivering high-quality medical oncology care? A national comparison of severe acute toxicity from systemic anti-cancer therapy

BackgroundIn the precision medicine era the complexity of systemic anti-cancer therapy (SACT) delivery and their associated toxicities have also increased. However, there has been little systematic assessment of the quality of care associated with systemic anti-cancer therapy delivery across national healthcare systems. We evaluated hospital-level severe acute toxicity rates during SACT treatment as a means of identifying variation in care quality. MethodsAll colorectal cancer (CRC) patients receiving SACT within 106 English National Health Service (NHS) hospitals between 2016 and 2019 were included.Severe acute toxicity rates were derived from hospital administrative data using a validated coding framework. Toxicity rates were adjusted for age, sex, comorbidity, performance status, tumour site, and TNM staging. Variation in hospital-level toxicity rates was assessed separately in the adjuvant and first-line metastatic settings. Results8,173 patients received SACT in the adjuvant setting, and 7,683 patients in the first-line metastatic setting. Adjusted severe acute toxicity rates varied between hospitals from 11% to 49% for the adjuvant cohort, and from 25% to 67% for the metastatic cohort.Compared to the national mean toxicity rate in the adjuvant cohort, six hospitals were more than 2 standard deviations (2SD) above, and four hospitals were more than 2SD below. In the metastatic cohort, six hospitals were more than 2SD above, and seven hospitals were more than 2SD below the national mean toxicity rate.Overall, 12 hospitals (12%) had toxicity rates more than 2SD above the national mean, and 11 (10%) had rates more than 2SD below. ConclusionThere is substantial variation in hospital-level severe acute toxicity rates in both the adjuvant and metastatic settings, despite risk-adjustment. Ongoing national public reporting of this performance indicator can be used investigate reasons for variation in toxicity rates and stimulate quality improvement initiatives to improve care. This may include increasing centralisation of SACT care delivery to minimise variation. This approach can be applied across different cancer types and in many different countries where similar regional or national clinical and administrative hospital datasets are available.

Age-related experiences of colorectal cancer diagnosis: a secondary analysis of the English National Cancer Patient Experience Survey

ObjectiveThe incidence of colorectal cancer (CRC) in people aged <50 years has been increasing dramatically in the past three decades and such patients are known to face difficulties in diagnosis....

Helping medical undergraduate students to understand healthcare costs.

Developing clinical leadership competencies in medical students ideally would be an experiential process. One crucial leadership competency in the UK Faculty of Medical Leadership and Management leadership framework, is ‘managing services’; a key aspect of this is being aware of healthcare costs. This is challenging within the crowded MBBS curriculum, with students naturally focused on their emergent diagnostic and clinical management skills. A pre-existing epidemiology assessment at St George's University of London (SGUL), the case analysis project (CAP), requires first year clinical students to investigate the sensitivity and specificity of screening and diagnostic tests and the treatment evidence base for a patient condition they have encountered clinically. To give students an appreciation of the cost of healthcare, this innovative extension of the project required that students additionally estimate the costs of both their chosen diagnostic tests and treatment. The students are provided with a tailored form of the English National Cost Collection for the NHS,1 an annually published spreadsheet of average costs for every test and treatment, ranging from phlebotomy to heart transplantation. The resource was downloaded, irrelevant content removed, and a simple costing methodology created, ignoring the database's subtle categorisations such as 'case complexity'. Students were directed to the British National Formulary for drug costs. A pre-recorded lecture and worked examples were prepared on the SGUL online learning platform, demonstrating the use of the tailored spreadsheet, and other resources, in estimating costs. Students are supported with their project by clinical and epidemiological tutors in two separate small group tutorials. A training session and access to student resources were provided to tutors, as this was unfamiliar content for them. During implementation, student queries which tutors could not answer were escalated to the CAP clinical academic lead. The tutor training session generated improvements in presentation of material and offered an opportunity to pilot the intervention with educators. Keeping the task simple, and our focus on developing clear training resources for students and tutors, were successful approaches as there were few student queries requiring escalation. Delivering the tutorials required no additional tutor time. Nearly all students costed investigations and treatments correctly. Tutors reported lively and engaged discussions around healthcare costs and encouraged students to use this resource in their future discussions and learning around health economics. The innovation was successful in achieving an appreciation of health service costs for medical students and giving them the opportunity to practise scholarship relating to a crucial leadership competency. Two challenges encountered by students were the different terminology used for tests in the database compared with clinical terms and locating the test or treatment, both issues were resolved within the tutorials. Finally, an important limitation is that the costings in the NHS database do not take account of ‘care’ provision, admission duration, costs for co-morbidities or indirect costs such as building maintenance/utilities. However, these limitations could be a focus for further expansion of this educational intervention, thus continuing the development of our future clinical managers and leaders.

Discursive and Narrative Practices of the Scottish Authorities in the Framework of the Implementation of the Agenda of National and Territorial Self-Determination of Scotland

The article analyzes the narrative and discursive practices of political forces aimed at achieving national-territorial sovereignty on the example of Scotland. The authors emphasize the relevance of the task of analyzing the reasons that allow some regions and peoples to be ficult to achieve sovereignty. According to the authors, it is precisely this context that suggests the need for a scientific understanding of the narrative and discursive practices of those political forces that implement the agenda of national-territorial self-determination in the real political process. The purpose of the study is to analyze the narrative and discursive practices of the Scottish Government and the Scottish National Party, the strategy and tactics of which are determined by the peculiarities of Scottish nationalism and the specifics of the identity of the Scots. Research methodology : to achieve this goal, the authors used a set of methods, among which the socio-cultural approach should be particularly noted, which makes it possible in the process of political analysis to consider the socio-political space through the prism of modern world and local civilizational processes, where the political sphere is influenced by socio-cultural factors. As a result of the analysis , the authors came to the conclusion that the discursive and narrative practices of Scottish nationalists contribute to the awareness of indigenous Scots of their own national specifics, which does not conflict with the identities of ethno-confessional minorities living in Scotland.

Negotiated belonging in sub-state nationalist contexts: young adult migrant narratives in Scotland and South Tyrol

This contribution investigates the intersection between macro-level political narratives on diversity and micro-level lived experience of social inclusion and everyday interaction. The case studies for analysis comprise of two regional sub-state nationalist contexts, Scotland and South Tyrol, Italy. Scotland is a nation state that defines itself vis-a-vis the rest of the UK and where a discourse has emerged that Scottish nationalism is both civic and inclusive. South Tyrol is an autonomous province in northern Italy which remains a liminal space between Austria and Italy and is presented as a model to protect minorities. We argue for developing a critical stance on diversity narratives identified in these two-regions. Based on in-depth narrative interviews with young adult migrants, we use an ontological security framework to examine the relationship between macro-narratives and micro-level lived experiences of everyday social interactions. Firstly, we address how macro-level national identity discourses manifest themselves in micro-level everyday interactions. Secondly, we look at how young adults interpret these narratives when retelling their everyday experiences, sometimes to the point of excluding their own experiences of discrimination. In this way, we trace the negotiation of belongingness in these two contexts.

Comparison of weight change between face-to-face and digital delivery of the English National Health service diabetes prevention programme: An exploratory non-inferiority study with imputation of plausible weight outcomes

Worldwide evidence suggests face-to-face diabetes prevention programmes are effective in preventing and delaying the onset of type 2 diabetes by encouraging behaviour change towards weight loss, healthy eating, and increased exercise. There is an absence of evidence on whether digital delivery is as effective as face-to-face. During 2017–18 patients in England were offered the National Health Service Diabetes Prevention Programme as group-based face-to-face delivery, digital delivery (‘digital-only’) or a choice between digital and face-to-face (‘digital-choice’). The contemporaneous delivery allowed for a robust non-inferiority study, comparing face-to-face with digital only and digital choice cohorts.Changes in weight at 6 months were missing for around half of participants. Here we take a novel approach, estimating the average effect in all 65,741 individuals who enrolled in the programme, by making a range of plausible assumptions about weight change in individuals who did not provide outcome data. The benefit of this approach is that it includes everyone who enrolled in the programme, not restricted to those who completed. We analysed the data using multiple linear regression models.Under all scenarios explored, enrolment in the digital diabetes prevention programme was associated with clinically significant reductions in weight which were at least equivalent to weight loss in the face-to-face programme. Digital services can be just as effective as face-to-face in delivering a population-based approach to the prevention of type 2 diabetes. Imputation of plausible outcomes is a feasible methodological approach, suitable for analysis of routine data in settings where outcomes are missing for non-attenders.

Using Citizen Voice to Evaluate Experiments on Politicians: A UK Survey Experiment

AbstractExperiments on the responsiveness of elected officials highlight the tension between the freedom to carry out research and the right of subjects to be treated with respect. Controversy emerges from the power of politicians to block or object to experimental designs using identity deception. One way to resolve this conundrum is to consult citizens who, as constituents of politicians, have an interest in promoting the accountability of elected representatives. Building on the work of Desposato and Naurin and Öhberg, this survey experiment presented research designs to UK citizens for their evaluation. The findings show that citizens strongly approve of experimental research on Members of Parliament (MPs) and are glad to see their representatives participate. There are no differences in support whether designs use identity deception, debriefing, confederates or pre-agreement from MPs. Linked to high interest in politics, more citizens are glad their MPs participate in studies using identity deception than those deploying confederates.

Weighing up the future: a meta-ethnography of household perceptions of the National Child Measurement Programme in England

ABSTRACT The English National Child Measurement Programme (NCMP) is a nationally mandated public health programme. It provides data for child excess weight indicators in the Public Health Outcomes Framework, part of the government’s approach to reducing childhood obesity. Drawing on a meta-ethnographic synthesis of household members’ experiences of the programme, we conceptualise the NCMP as a ‘technique of futuring’ to generate new insights into how it (re)shapes and (re)imagines past, present, and future responsibilities and practices for overweight children, parents, and carers, in potentially harmful ways. For children categorised by the NCMP as overweight, the NCMP is an emotionally significant event, driving new bodily practices, new food practices and changed relationships with peers. This paper outlines how parents come to resist and reframe the programme and its results, to protect their children from a weight-focused future. They consider the potential risks of bullying, dysfunctional eating, and mental health consequences more important than future risks of overweight. We show how parents of children categorised as overweight preserve their claim to ‘responsible’ and ‘good’ parenting amongst peers, whilst shifting the blame for childhood obesity to other, ‘irresponsible’ parents, thus reproducing moralising and responsibilising discourses inherent within the ‘behaviour change’ messaging of the NCMP and associated research. Finally, we consider a central paradox of this programme and the use of NCMP population level monitoring data to (re)shape lives at the individual and social level – the children it sets out to help are the most likely to experience harm as a result of it.

Hospital resource endowments and nosocomial infections: longitudinal evidence from the English National Health Service on Clostridioides difficile between 2011 and 2019

To identify key factors associated with Clostridioides difficile infections (CDI) in healthcare at the hospital organization level. Longitudinal study covering the period 2011-2019. Hospital reports were analysed to determine the number of CDI and several hospital-related environmental factors: financial resources (i.e., cleaning expenditure), spatial resources (i.e., number of single rooms with a private bathroom), human resources (i.e., number of physicians and nursing staff), and cultural resources (i.e., error reporting climate). The relationships between the environmental factors and CDI were analysed in a hybrid within- and between-hospital random-effect model. 129 general hospital Trusts operating in the English National Health Service (NHS). All inpatients in 129 general hospital trusts of the NHS in the years 2011-2019, covering 120,629 cases of CDI. Annual number of CDI per hospital trust. Single rooms were associated with fewer CDI at the within-hospital level, but not at the between-hospital level. Similarly, more nursing staff was associated with fewer CDI at the within-hospital level, but not at the between-hospital level. This effect was not observed for physician staffing. A different picture emerged for the protective effect of cultural resources, with a weakly significant effect of between-hospital differences, but no within-hospital effect. Financial resources were not associated with CDI either between hospitals or within them over time. The present study identified hospital resources with a beneficial influence on CDI rates. Health care organizations can use this knowledge for active CDI prevention.

Cost-Utility Analysis of the Caresyntax Platform to Identify Patients at Risk of Surgical Site Infection Undergoing Colorectal Surgery.

Surgical site infections (SSIs) account for up to 18% of all healthcare-associated infections (HAIs). The Caresyntax data-driven surgery platform incorporates the most common risk factors for SSI, to identify high-risk surgical patients before they leave the operating theatre and treat them prophylactically with negative pressure wound therapy (NPWT). An economic analysis was performed to assess the costs and health outcomes associated with introduction of the technology in the English healthcare setting. A hybrid decision tree/Markov model was developed to reflect the treatment pathways that patients undergoing colorectal surgery would typically follow, both over the short term (30-day hospital setting) and long term (lifetime). The analysis considered implementation of Caresyntax's platform-based SSI predictive algorithm in the hospital setting, compared with standard of care, from an English National Health Service (NHS) perspective. The base-case analysis presents results in terms of cost per quality-adjusted life-year (QALY) gained, as well as operational impact. The base-case analysis indicates that the intervention leads to a cost saving of £55.52m across the total NHS colorectal surgery patient population in 1year. In addition, the intervention has a 98.36% probability of being cost effective over a lifetime horizon. The intervention results in the avoidance of 19,744 SSI events, as well 191,911 excess hospital bed days saved. Caresyntax's platform-based SSI predictive algorithm has the potential to result in cost savings and improved patient quality of life. Additionally, operational gains for the healthcare provider, including reduced infection rates and hospital bed days saved, have been shown through the economic modeling.

Many Mouths: The Politics of Food in Britain from the Workhouse to the Welfare State, by Nadja Durbach

Reviewed by: Many Mouths: The Politics of Food in Britain from the Workhouse to the Welfare State by Nadja Durbach Rebecca Earle (bio) Many Mouths: The Politics of Food in Britain from the Workhouse to the Welfare State, by Nadja Durbach; pp. xii + 363. Cambridge and New York: Cambridge University Press, 2020, £36.99, £30.00 ebook, $46.99, $38.00 ebook. Many Mouths: The Politics of Food in Britain from the Workhouse to the Welfare State explores a series of occasions when the modern British state undertook to feed “some members of its population (but not others) and what government food meant to those who devised, those who executed, those who used, and those who refused the state’s alimentary interventions” (17). These programs of state feeding were motivated by a range of concerns; discontent over the mounting cost of poor relief, desire to ensure the robustness of the labor supply, anxieties that hungry children would be unable to benefit from state education, and humanitarian responses to famine (among other factors) all shaped the diverse occasions on which the modern British state sought to provide food for sections of the population. Precisely because these programs responded to diverse situations, the responses were themselves inconsistent and incoherent, Durbach argues. History, she writes, reveals “no arc of progressive change” (245); she does not trace “a growing state interest in feeding its citizens” (5). Rather, her themes are the agency exercised by the recipients of state feeding, the important role of local authorities in implementing, and modifying, national initiatives, and the limited impact of nutritional science in shaping any of these policies. A particular strength is Durbach’s sustained attention to Britain’s status as an empire. State feeding initiatives demonstrate clearly the unequal levels of responsibility the government felt toward ensuring that different imperial subjects were not hungry. Many Mouths explores these themes through a series of case studies ranging from debates over the provision of Christmas meals in Victorian workhouses to the efforts of the Welfare Foods Service to supply orange juice to small children during and after the Second World War. Other chapters study, inter alia, the attempts to design standard dietaries for nineteenth-century prisons, the principles governing eligibility for free school meals in the interwar years, and the unexpected popularity of British restaurants. Weaving together these case studies are helpful historical synopses that provide a framework for understanding the specificities of each example. The book is based on extensive research in the United Kingdom’s National Archives and other repositories, a mass of printed primary sources, and much engagement with the [End Page 729] considerable scholarship on the evolution of the British diet, biopolitics, and other relevant topics. The result is a readable, compelling, and authoritative book that adds greatly to our understanding of the complexities shaping the alimentary interventions that Durbach studies. Her use of case studies is intended to underscore the contingency and variability of these interventions. Officials rarely learned from past experiences of state feeding, were inconsistent in their use of nutritional science, and responded more to the specifics of each situation than to broader comparisons with other state feeding programs. Consistency, indeed, was rarely the goal. To be sure, as Durbach concedes, there were some overarching trends; over the twentieth century the state began to accept some responsibility for supporting the wellbeing of all members of the nation, but Durbach’s focus is on the “messiness” of these processes (4). As much as she identifies change, she stresses unexpected continuities linking (for instance) Charles Trevelyan and the 1943 London Council of Social Service: both decried the provision of subsidized food to unde-serving eaters. What did it mean to receive food from the state? On occasion, it meant a recognition of the recipient’s membership in the body politic. When inhabitants of the work-house demanded the Christmas meal of roast beef, plum pudding, and beer abolished by the New Poor Law, they were affirming their rights as British citizens to participate in the cultural life of the nation. For this very reason, the guardians of some workhouses refused to comply with the prohibition, allowing inmates this customary “old English fare” on holidays...

Editorial introductions.

Editorial introductions.

Developing architecture of system management in the English NHS: evidence from a qualitative study of three Integrated Care Systems

ObjectiveIntegrated Care Systems (ICSs) mark a change in the English National Health Service to more collaborative interorganisational working. We explored how effective the ICS form of collaboration is in achieving...

Mental health coverage for forced migrants: Managing failure as everyday governance in the public and NGO sectors in England.

High-income countries (HICs) which are said to have "reached" universal health coverage (UHC) typically still have coverage gaps, due to both formal policies and informal barriers which result in "hypothetical access". In England, a user fee exemption has in principle made access to treatment for post-traumatic stress disorder (PTSD) and other mental health conditions thought to be caused by certain forms of violence universal, regardless of immigration status. This study explores the everyday governance of this mental health coverage for forced migrants in the English National Health Service (NHS) and NGO sector. Fieldwork was conducted in two waves, in 2015-2016 and 2019-2021, including six months of participant observation in an NGO and 21 semi-structured interviews with psy professionals across 16 NHS and NGO service providers. Further interviews were conducted with mental health commissioners and policymakers, as well as analysis of grey literature. Despite being formally covered for certain types of mental health care, in practice asylum seekers and undocumented migrants were often excluded by NHS providers. Undocumented migrants were also often excluded by NGO providers. Several rationalities linked discursive fields to practices developed by psy professionals and other street-level bureaucrats to govern coverage, in a process of "managing failure". These rationalities are presented under three paired themes which draw attention to tensions and resistance in the governance of coverage: medicalisation and biolegitimacy; austerity and ethico-politics; and differential racialisation and decolonisation. Rationalities were associated with strategies and tactics such as social triage, clinical advocacy, obfuscation, evidence-based advocacy and silencing critique. The concept of "health coverage assemblage" is introduced to explain the complex, unstable, contingent and fragmented nature of UHC policies and programmes. Misrecognition and underestimation of the everyday work of health professionals in promoting, resisting and reproducing diverse rationalities within the assemblage may lead to missed opportunities for reform.

The vulnerability of in-between statuses: ID and migration controls in the cases of the ‘Windrush generation’ scandal and Brexit

ABSTRACT In this article, I argue that identity documents (ID) and migration statuses are both tools of population control and subjectivities that individuals have an interest in holding. I use documentary analyses and interviews with 31 EU27 citizens in the UK, 21 UK citizens in Belgium and the UK and with nationality bureaucracies in the two countries. States create legitimate, illegitimate and in-between statuses, and in-between statuses show how being exempt from certain ID and migration controls can create paradoxical vulnerabilities. Windrush generation migrants in the UK were exempt from migration controls but then in some cases were treated as irregular migrants because of the lack of proof of status. EU citizens were free from many migration controls, but can have difficulties in naturalization and dealing with new requirements brought about by Brexit because the procedures can require proof of rights usually produced through the migration controls they were exempt from.

Bordering seafarers at sea and onshore.

This study uses a historically informed lens of coloniality, bordering, and intersectionality to analyze maritime bordering discourses and practices that target seafarers recruited from the Global South who embody the border in their everyday lives. In seeking to explain the current context exemplified by the sacking of P&O Ferry workers and the recruitment of "foreign agency" crews in March 2022, the study foregrounds 19th- and 20th-century maritime bordering legislation on ships and onshore, focusing on public-/private-bordering partnerships between governments, shipping companies, and unions. Archival research on British Indian seafarers employed by P&O a century ago and analysis of contemporary media and political discourses relating to "foreign agency crews" are drawn on to consider the implications of earlier bordering discourses and practices for 21st-century British citizenship and belonging. Attending to imperial bordering regulations that created the racialized and class-defined labor category of lascars explains the "common sense" designations of seafarers recruited in the Global South and their families as potential "illegal migrants," and in doing so, it constitutes the long history of the public/private partnerships that constitute the UK's "hostile environment" immigration policies.

AI telemedicine screening in ophthalmology: health economic considerations

AI telemedicine screening in ophthalmology: health economic considerations

Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada.

Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada. We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury. The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. "scoop and run" in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09-1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52-0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries. We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement.

Health-risk behaviours among people with severe mental ill health: understanding modifiable risk in the Closing the Gap Health Study.

People with severe mental ill health (SMI) experience some of the largest health inequalities of any sector within society. For these inequalities to be reduced, an understanding of the behavioural determinants of health in this population is needed. Utilising data from the Closing the Gap Health Study, we aimed to assess the extent to which people with SMI report health-risk factors and behaviours, their interest in modifying them, and the factors associated with being motivated to modify these behaviours. Adult (≥18 years old) participants were recruited via primary and secondary care in the English National Health Service. To be eligible, participants needed to have a documented diagnosis of schizophrenia, psychotic disorders or bipolar disorder. Data were collected by survey on demographics, general physical health, diet, physical activity, alcohol, smoking and body mass index. Between April 2016 and March 2020, n = 9914 participants were recruited. Among people with SMI, high rates of obesity (37.5%), infrequent physical activity (62.0%), not meeting current guidelines (≥5) for the consumption of fruit and vegetables (85.0%) and smoking (42.2%) were observed. However, most participants were motivated to reduce health-risk behaviours. Perceiving the importance of health-promoting behaviours, being of poorer general health and being female were significantly associated with being motivated to modify health-risk behaviours. Despite experiencing poor physical and mental health outcomes compared with the general population, and contrary to popular misconceptions, people with SMI perceive health as important and are motivated to make behavioural changes to improve health.

Ordinary People and the 1979 Royal Commission on the NHS.

In June 1979, the Royal Commission on the National Health Service published its report. Chaired by Sir Alec Merrison, the Commission covered England, Scotland, Wales and Northern Ireland. In 1976, the Royal Commission published and broadcast calls, asking the public to put forward their views on the NHS. In response, they received around 2,460 written evidence submissions, held fifty-eight oral evidence sessions, and met with about 2,800 individuals. In soliciting evidence, the Commission called on people to comment on their experience of the health service, submit that experience as evidence, and contribute suggestions for the NHS's improvement. These submissions of evidence, mostly in the form of letters written to Merrison, are rich and revealing sources. While NHS staff, trade unionists, and professional organizations were invited to contribute their perspectives, patients and other non-clinical members of the British public also penned letters. In this article, I use the evidence submitted by self-proclaimed 'ordinary' people to contribute to emerging discussions about post-war British citizenship, and its intimate or quotidian relationship to the welfare state. I use these submissions as evidence for popular anxieties in the 1970s, and to explore the various ways that British citizens experienced and engaged with the NHS; investigate how they felt about its services; and consider the affective and political function of complaint.