North West London Research Articles

Development of a nurse-led paediatric inflammatory bowel disease service

The incidence of paediatric-onset inflammatory bowel disease (IBD) is increasing, and treatment pathways are becoming more complex. Therefore, it is necessary to develop services that are able to manage these patients appropriately with consideration of national and international guidelines. It is important to recognise children are not just small adults and their needs are different to adult patients with IBD. This article discusses the process of establishing a paediatric IBD service at Northwick Park Hospital with the support of the adult IBD nursing service at St Mark's Hospital. Both hospitals are co-located on the same site as part of the London Northwest Healthcare Trust. The new role was designed to be managed jointly by the paediatric matron and adult IBD lead nurse to ensure the appropriate aspects of both specialties were reflected in the new service.

Evaluation of a newly introduced tonsillectomy operation record for the analysis of regional post-tonsillectomy bleed data: a quality improvement project at the London North West Healthcare NHS Trust

The primary objective of this audit and quality improvement project was to retrospectively analyse regional post-tonsillectomy haemorrhage data as per national recommendations. However, this process highlighted the need for high-quality routinely collected data; something that was not always available via retrospective audit and thus does not enable formal aetiological factor analyses. We therefore created further secondary objectives to facilitate our primary audit objective. These secondary objectives were (1) to introduce a standardised tonsillectomy operation proforma to improve completeness and quality of routinely collected data and (2) to evaluate and validate proforma use and usefulness in improving using routine data collection to help with a repeated audit of post-tonsillectomy haemorrhages with the eventual aim to help improve operative outcomes by identifying potential associated factors. The retrospective audit component, the prospective audit and the quality improvement component were all carried out at the Northwick Park Hospital and Central Middlesex Hospital (London North West Healthcare NHS Trust). First, 642 tonsillectomy records (2012–2014) were retrospectively reviewed. Free-text operative documentation and, where possible, potential factors associated with post-tonsillectomy haemorrhages were analysed. In addition, completeness of data available before and after the introduction of (A) a new paper-based and (B) electronic surgical record proforma was reviewed (2014–2015). Over a 2-year period, 62 of the 642 (9.7%) audited tonsillectomy patients had a post-tonsillectomy haemorrhage, and 19 of these (2.9%) had to return to theatre for surgical arrest of the haemorrhage. Bipolar diathermy was the most commonly used technique. During this period, data available from routine operative documentation in the surgical operation notes were variable and thus did not allow identification of potential factors associated with post-tonsillectomy haemorrhage. The completeness and quality of data significantly improved after the introduction of a standardised paper-based proforma with sections for required details based on known risk factors for post-tonsillectomy haemorrhage and required operative details. Quality and completeness of data was further improved after the introduction of an electronic version. This electronic proforma will allow prospective spiral auditing results, early identification of raised bleeding rate, and provide individual surgeon audit results.

Deriving a management algorithm for emphysematous pyelonephritis: Can we rely on minimally invasive strategies or should we be opting for earlier nephrectomy?

To analyse the incidence and management of emphysematous pyelonephritis (EPN) in North West London and examine factors that influence immediate and 6-month outcomes with the aim of guiding future management. This work analyses EPN cases from the London North West Healthcare NHS Trust from October 2006 to July 2015 (population≈850,000). Diagnosis and stage were confirmed by computed tomography (CT). Demographic, clinical, biochemical and microbiological characteristics were assessed. Treatment modalities were medical management, minimally invasive management (MIM) and surgical. Immediate and 6-month outcomes were analysed. Thirteen cases were identified (f=8, m=5) from 5525 CT scans. EPN occurred in patients with diabetes mellitus (n=11, 84.6%), hypertension (n=10, 76.9%) or urinary tract calculi (n=7, 53.85%). Unilateral EPN occurred predominantly (n=11, 84.6%); 46.1% (n=6) were class 1 or 2 and 53.8% (n=7) class 3 or 4. Escherichia coli was most commonly cultured (n=5, 38.46%). All patients received antibiotics, and ten cases required MIM. Two patients had a delayed nephrectomy, both survived. Mortality was 15.4% (n=2, grade 1 and 3a), both died acutely post-MIM, neither underwent emergency nephrectomy. At 6months, eight patients had ongoing renal impairment. No specific poor prognostic factors were identifiable. Patients with low-grade EPN may also have a high mortality rate. In the two cases who died, earlier consideration for nephrectomy may have been prudent. It may be beneficial to have a low threshold for prompt emergency nephrectomy in severe cases and where MIM treatment has failed. We suggest a management algorithm to guide clinicians and minimise mortality.

What makes a sustainability tool valuable, practical and useful in real-world healthcare practice? A mixed-methods study on the development of the Long Term Success Tool in Northwest London

ObjectivesAlthough improvement initiatives show benefits to patient care, they often fail to sustain. Models and frameworks exist to address this challenge, but issues with design, clarity and usability have been...

Developing an improvement leaders fellowship programme and the evaluation of the integration of patient fellows

1) The National Institute for Healthcare Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London (NWL) has run an Improvement Leader Fellowship programme since 2010. A one year multi-disciplinary, improvement science capacity building programme built around a work based learning model and an improvement project delivering healthcare improvement on the ground. This innovative educational programme works to engage patients and mobilise knowledge across patient professional boundaries. 2) The multidisciplinary perspective of quality improvement and the pedagogical theory behind improvement science teaching and application are considered along with the challenges and practicalities of co-producing education with patients in this programme. Patients have been involved in the programme since 2012, the evaluation considers the impact of involving patients both for the patients themselves and the other Fellows in the multi-disciplinary group. 3) Eighty five Fellows have passed through the programme, fifteen of whom have been patients. The session will discuss the independent evaluation of four cohorts and considers the impact of the integration of patient fellows in the programme. Patient Fellows have delivered sessions within the programme, these co-produced sessions highlight the expertise that patient leaders can bring to the table. 4) Semi-structured interviews were conducted with 34 fellows, and analysed using grounded theory. Thematic analysis shows the Fellows responded positively to the multi-disciplinary approach. The inclusion of patient Fellows in the cohort resulted in a period of adjustment for both professionals and patients, independently reported by either group. 5) Concepts such as the zone of proximal development, productive struggle and participatory knowledge spaces are highlighted as theoretical underpinnings to explore the observed phenomena in the Fellowship. 6) The lesson learned were multiple, the challenges arising from the integration of patients rose a number of levels including practical (financial) and human (conflict resolution, unfounded fears) 6) Limitations included the small cohort sizes, also the intangibility and difficulty in capturing methodologically the personal development of fellows. 7) Future research may wish to consider a social network analysis of alumni fellow groups to more fully capture the education and personal development of both clinician and patient fellows.

Prioritizing medication safety in care of people with cancer: clinicians' views on main problems and solutions.

BackgroundCancer care is liable to medication errors due to the complex nature of cancer treatment, the common presence of comorbidities and the involvement of a number of clinicians in cancer care. While the frequency of medication errors in cancer care has been reported, little is known about their causal factors and effective prevention strategies. With a unique insight into the main safety issues in cancer treatment, frontline staff can help close this gap. In this study, we aimed to identify medication safety priorities in cancer patient care according to clinicians in North West London using PRIORITIZE, a novel priority–setting approach.MethodsThe project steering group determined the scope, the context and the criteria for prioritization. We then invited North West London cancer care clinicians to identify and prioritize main causes for, and solutions to, medication errors in cancer care. Forty cancer care providers submitted their suggestions which were thematically synthesized into a composite list of 20 distinct problems and 22 solutions. A group of 26 clinicians from the initial cohort ranked the composite list of suggestions using predetermined criteria.ResultsThe top ranked problems focused on patients’ poor understanding of treatments due to language or education difficulties, clinicians’ insufficient attention to patients’ psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre–chemotherapy work–up for all patients and better staff training. Overall, clinicians considered improved communication between health care providers, quality assurance procedures (during prescription and monitoring stages) and patient education as key strategies for improving cancer medication safety. Prescribing stage was identified as the most vulnerable to medication safety threats. The highest ranked suggestions received the strongest agreement among the clinicians.ConclusionsClinician–identified priorities for reducing medication errors in cancer care addressed various aspects of cancer treatment. Our findings open up an opportunity to assess the congruence between health care professional suggestions, currently implemented patient safety policies and evidence base.

Screening can reduce GBS risk.

Screening pregnant women for bacterial infection Group B Streptococcus (GBS) can cut the risk to newborns dramatically, a study from London North West Healthcare NHS Trust suggests.

Complications of miliary tuberculosis: low mortality and predictive biomarkers from a UK cohort

BackgroundUntreated, miliary tuberculosis (TB) has a mortality approaching 100%. As it is uncommon there is little specific data to guide its management. We report detailed data from a UK cohort of patients with miliary tuberculosis and the associations and predictive ability of admission blood tests with clinical outcomes.MethodsRoutinely collected demographic, clinical, blood, imaging, histopathological and microbiological data were assessed for all patients with miliary TB identified from the London TB register from 2008 to 2012 from Northwest London Hospitals NHS Trust. Multivariable logistic regression was used to assess factors independently associated with the need for critical care intervention. Receiver operator characteristics (ROC) were calculated to assess the discriminatory ability of admission blood tests to predict clinical outcomes.ResultsFifty-two patients were identified with miliary tuberculosis, of whom 29% had confirmed central nervous system (CNS) involvement. Magnetic resonance imaging (MRI) was more sensitive than computed tomography (CT) or lumbar puncture for detecting CNS disease. Severe complications were frequent, with 15% requiring critical care intervention with mechanical ventilation. This was independently associated with admission hyponatraemia and elevated alanine aminotransferase (ALT). Having an admission sodium ≥125 mmol/L and an ALT <180 IU/L had 82% sensitivity and 100% specificity for predicting a favourable outcome with an area under the ROC curve (AUC) of 0.91. Despite the frequency of severe complications, one-year mortality was low at 2%.ConclusionsAlthough severe complications of miliary tuberculosis were frequent, mortality was low with timely access to critical care intervention, anti-tuberculous therapy and possibly corticosteroid use. Clinical outcomes could accurately be predicted using routinely collected biochemistry data.

'Learn from others by listening'.

Claire Taylor qualified as a nurse 30 years ago, gaining a Bachelor of Nursing degree at the University of Southampton. A Macmillan professional for more than 20 years, she has worked in a variety of clinical posts and been a lecturer in gastrointestinal (GI) nursing at King's College London. She has been Macmillan nurse consultant in colorectal cancer at London North West Healthcare NHS Trust since 2015.

Prioritizing problems in and solutions to homecare safety of people with dementia: supporting carers, streamlining care

BackgroundDementia care is predominantly provided by carers in home settings. We aimed to identify the priorities for homecare safety of people with dementia according to dementia health and social care professionals using a novel priority-setting method.MethodsThe project steering group determined the scope, the context and the criteria for prioritization. We then invited 185 North-West London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to homecare safety of people with dementia. 76 clinicians submitted their suggestions which were thematically synthesized into a composite list of 27 distinct problems and 30 solutions. A group of 49 clinicians arbitrarily selected from the initial cohort ranked the composite list of suggestions using predetermined criteria.ResultsInadequate education of carers of people with dementia (both family and professional) is seen as a key problem that needs addressing in addition to challenges of self-neglect, social isolation, medication nonadherence. Seven out of top 10 problems related to patients and/or carers signalling clearly where help and support are needed. The top ranked solutions focused on involvement and education of family carers, their supervision and continuing support. Several suggestions highlighted a need for improvement of recruitment, oversight and working conditions of professional carers and for different home safety-proofing strategies.ConclusionsClinicians identified a range of suggestions for improving homecare safety of people with dementia. Better equipping carers was seen as fundamental for ensuring homecare safety. Many of the identified suggestions are highly challenging and not easily changeable, yet there are also many that are feasible, affordable and could contribute to substantial improvements to dementia homecare safety.

An Economic Evaluation of Continuous Glucose Monitoring for People with Type 1 Diabetes and Impaired Awareness of Hypoglycaemia within North West London Clinical Commissioning Groups in England.

To assess the economic impact of providing real time continuous glucose monitoring (CGM) for people with type 1 diabetes (T1D) and impaired awareness of hypoglycaemia (IAH) within North West (NW) London clinical commissioning groups (CCGs). Methods: The eligible population for CGM and inputs for the economic budget impact model developed were derived from published data. The model includes cost of CGM; cost savings associated with lower hypoglycaemia related hospital admissions, accidents and emergency visits; self-monitoring of blood glucose (SMBG) strip usage; and glycated haemoglobin (HbA1c) reduction-related avoided complications and insulin pump use. Results: The cost of CGM for T1D-IAH (n=3,036) in the first year is £10,770,671 and in the fourth year is £11,329,095. The combined cost off-sets related to reduced hypoglycaemia admissions, SMBG strip usage and complications are £8,116,912 and £8,741,026 in years one and four, respectively. The net budget impact within the NW London CCGs is £2,653,760; £2,588,068 in years one and four respectively. Conclusions: Introduction of CGM for T1D-IAH patients will have a minimal budget impact on NW London CCGs, driven by cost of CGM and offsets from lower hypoglycaemia-related costs, reduced SMBG strip usage, avoided HbA1c-related complications and lower insulin pump use.

Research award for North West London Local Practice Forum

Research award for North West London Local Practice Forum

Developing Integrated Care Teams Across the North West London System

Developing Integrated Care Teams Across the North West London System

Why Implementing Integrated Care is so much harder than designing it: experience in North West London. England

Introduction: Delivering more integrated care has long been a priority in England. Both care quality and cost effectiveness have been seen to require effective collaboration between local government and the NHS. Despite repeated national programmes and some localised progress, success has never been universalised. The recent Coalition Government launched several initiatives to enable integrated care to ‘become the standard model for everyone with health and care needs’ (Hunt and Lamb 2013). Among these initiatives was the establishment of ‘integration pioneers’ in the ‘most ambitious and visionary areas’ to ‘help to get the ball rolling’ and share ‘every lesson learned’. In return, central government promised support to remove national barriers to integration. The Whole Systems Integrated Care (WSIC) programme in North West London (NWL) was the largest pioneer in terms of population (2.4million) and partners (31 agencies). This paper reports on an initial evaluation conducted by its authors between January 2014 and May 2015. Theory/Methods: A primarily qualitative evaluation with a strong formative element was commissioned to provide ongoing feedback and independent assessments of: - How WSIC was designed; - Stakeholder involvement; - Early implementation of pilot schemes; - How far WSIC appeared on track to meet its objectives. Data were collected through documentary analysis, non-participant observation, 73 interviews, workshops, a focus group, and two web-based surveys. The interviews and focus group were recorded, transcribed and analysed using NVivo. Emerging findings were fed back in round table sessions to help structure reflections on progress. Results: - WSIC built on lessons identified by an earlier evaluation in NWL (Curry et al 2013). It was ambitious and well resourced from funds pooled by the eight CCGs: £14.9m over the first two years of which most (£7.9m) was spent on management consultancy to address barriers to integration and lead a co-design. - A programme team developed a timetabled process for integrated care to become ‘business as usual’ from April 2015. A key principle was to save time and resources by addressing problems once rather than in each of eight local areas. - The initial co-design phase was completed largely on time. However, the programme was more than a year behind schedule when our evaluation ended and had yet to deliver significant service change. Only two of eight early adopter projects had begun operations by April 2015. - By late April 2015, the WSIC programme was seen to be approaching a ‘tipping point’. Changes in the programme’s leadership created concerns about its strategic management capacity and the need to demonstrate its ability to deliver change was considered increasingly urgent. Discussion: - A complex mix of enablers and barriers with local and national origins was considered responsible for the relative success of the design stage and the much slower progress subsequently. Co-design, inclusivity (especially of lay partners), an openness to learning, a clear, timetabled route map, together with roles of the programme management team and its resources were seen as valuable enablers. - However, the transition from planning to implementation and roll out of Early Adopters proved more difficult than anticipated. While some of the barriers could be addressed locally, others ultimately required action by central government. Among the former, the programme struggled to find the balance between, for example: collective leadership and local autonomy; integrated commissioning and integrated provision; NHS leadership and local authority engagement; local variation and programme-wide consistency; investment in design and support for ongoing implementation and change. - Managing such tensions is integral to such a programme and requires capabilities in systems leadership. NHS leaders have relatively little training or experience in managing systems as opposed to organisations.(Timmins, 2015). - National barriers slowing progress included difficulties in: securing data-sharing and information governance; developing payment and accountability systems aligned with integrated care objectives; enabling local government to be more equal partners especially when their finances were cut more heavily than the NHS; maintaining acute provider viability while reducing hospital admissions; balancing completion and collaboration. - Many of these barriers were identified before the Pioneer initiative but, despite the national commitment to remove them, little progress has yet been made. Conclusion: The distinction between local and national barriers and facilitators is an analytical one. In practice, they are interdependent. The NWL case shows the importance of developing effective local systems leadership capabilities within a national framework structured to support such leadership. It also highlights the need to ensure integration barriers are removed during the design stage and that the transition from design to delivery is planned and supported.

Home ward Ealing: commissioners and providers working together to deliver a new integrated model of intermediate care

The London Borough of Ealing is in the centre of eight boroughs which make up North West London, and has been part of a pioneering programme of whole systems approaches to integrated care since 2011. Ealing : The borough is one of the largest, most diverse and densely populated in London, with the largest Somali population in the UK and Sikh, Hindu and Muslim populations are significantly higher than the London average. The borough has areas of affluence and deprivation and large number of patients in hard to reach groups including those who are homeless or with problematic use of alcohol or drugs. Ealing’s population is above the national upper quartile for diabetes, and with an aging population across North West London, there is a growing number of patients suffering from other long term conditions including asthma, coronary heart disease, COPD and heart failure. Due to the geography of Ealing, a high proportion of patients from the borough are admitted to acute hospitals in neighbouring areas. Integrated Intermediate Care Service : In 2015, Ealing Clinical Commissioning Group in conjunction with the Local Authority, reprocured a newly specified integrated intermediate community care service for Ealing patients, which was designed with clinicians to provide a rapid, more responsive service that maximises admission avoidance and supports early discharge through managing a wide range of patients in a sub-acute phase in which they may need more than GPs and other community services can offer, but do not need an acute hospital bed. West London Mental Health NHS Trust led a group of other local providers from primary care, community care and secondary care, and worked with social services to develop an innovative delivery partnership which was designed to offer triple integration (vertically, with social care and mental health care), to maximise relationships with services in neighbouring boroughs, and to be delivered through accessing a single electronic patient record, shared with primary care. Together, the providers launched *Home ward Ealing* on 01 October 2015, and are collaboratively working in an open-book manner with commissioners to evolve the service to meet the needs of Ealing residents. Outcomes and obstacles overcome : We present outcomes and activity data from the predecessor service and the first six months of Home ward Ealing and outline the approaches taken to working across organisational boundaries, including the sharing of information, financial and clinical risk in an innovative integrated approach. We also outline links with other Ealing integrated care initatives, including Care Coordination and Navigation, Primary Care Mental Health and Dementia Link Workers and public health (Smoke Free Ealing) as part of a population health approach.

North West London Whole Systems Integrated Care: a case study

Introduction: North West London (NWL) has a population of over 2 million people and an annual health and social care spend of over £4bn. We have a diverse, growing and ageing population and need to make best use of resources in order to respond to changing needs. Change implemented: In 2013 partners from across the health and social care system began a journey towards Whole Systems Integrated Care (WSIC) that, when completed, will see us delivering new person-centred models of care, jointly commissioned and delivered across organisational boundaries. During the initial 8 month ‘co-design phase’ over 200 stakeholders from health, social care, service users and carers co-produced a framework - the Integrated Care Toolkit - for the delivery of integrated care in NWL. Following the publication of the Toolkit, 9 collaborative ‘Early Adopter’ partnerships began to translate the Toolkit into local delivery models, initially focussing people aged over 65. A number of these new service models have begun to go live in 2015. New models addressing the needs of further population groups will be implemented from 2016 onwards with the ambition of fully comprehensive coverage by 2018. Key findings: The Integration Toolkit, which is freely available on-line at http://integration.healthiernorthwestlondon.nhs.uk , has proved a useful starting point for the development of new models of care locally and has been viewed widely both nationally and internationally. Once local implementation got underway, the need for more detailed guidance about financial flows, governance and shared data became clear and a new set of handbooks were developed to provide specific support on operational, legal and delivery considerations and were consolidated into a ‘Toolbox’. An evaluation of the design phase was carried out by the Nuffield Trust and London School of Economics. Their report identified some of the themes below. Highlights: - The importance of co-design; building a common vision and framework grounded in the needs of the service user provides a strong foundation for transformation but takes time and can be challenging. The principle of co-design continues to be relevant passed the initial production of the framework however its role and focus needs to adapt and change. - Maintaining a balance between local and system-level focus; whilst there is clear value in working at scale to build momentum, reduce duplication and ensure consistency and stability at system level, there is a need to embed ownership locally to make changes relevant and sustainable - Integrated data is critical to integrated care; shared data is necessary for both the commissioning and delivery of effective person-centred integrated care. The multiplicity of systems and the information governance that underpins them has provided a considerable challenge. Developing the right capabilities and capacity in the system to utilise the data produced is a critical consideration as we move into implementation. - New ways of working; underpinning our programme are new models of care that require systemic behaviour change. We have developed a ‘Change Academy’ that brings teams together alongside service users to innovate new ways of working, break down organisational and professional barriers and ensure that the patient is at the centre of their care. - System-wide transformation takes time; the in-year ‘invest to save’ approach of most statutory change programmes does not take into account the time it takes to embed new models of care. Our initial timelines were ambitious and implementation has not happened as quickly as initially anticipated. The management of expectations with regards to timelines and benefits realisation is critical so that stakeholders (both local and national) do not become disillusioned with the ambitious work being undertaken. Conclusion: As one of 25 integrated care ‘Pioneers’ in England we are part of a community that shares challenges and the approaches being taken to address them. There is a striking commonality to the problems we face in implementing integrated care including; defining an organising principle for commissioning and delivering care; the operationalization of accurate and timely information sharing; the development of commissioning and contracting methodologies that embed joint accountability and the mainstreaming of new ways of working that bring teams of people together to meet the needs of the populations they serve. The ways in which we are addressing these challenges are not necessarily right or appropriate outside of NWL but they provide a case study for the design and delivery of integrated care at scale from which it is hoped there are lessons that may be valuable and applicable elsewhere.

A Mixed Methods Evaluation of the Northwest London Integrated Care Pilot

The National Health Services (NHS) within inner Northwest London implemented a transformational change pilot program for integrated care from 2011-13. This pilot focused on two populations within the inner northwest quadrant of London: diagnosed diabetics and the elderly over 75 years of age. An information technology (IT) tool was used to pool data across primary, secondary, community, social, and mental health care sectors in order to assess an integrated approach to care coordination. The network of service providers included: 5 social care services; 3 community care services; 106 primary care practices; 2 mental health facilities; 2 hospitals; and 2 non-profit organizations. Some of the main goals of the pilot were to: improve health outcomes among diabetics and the elderly; improve patient experience; reduce service outcomes such as emergency hospital admissions; create care plans for the targeted populations; and establish multidisciplinary case reviews of high-risk patients with the most complex needs. A mixed methods evaluation was essential for assessing the care process and health outcomes of the pilot. Results of the evaluation will be presented, particularly as they relate to clinical outcomes and quality of care, as well as patient and professional experience throughout the integrated care process.

Preventing delayed diagnosis of cancer: clinicians’ views on main problems and solutions

BackgroundDelayed diagnosis is a major contributing factor to the UK’s lower cancer survival compared to many European countries. In the UK, there is a significant national variation in early cancer diagnosis. Healthcare providers can offer an insight into local priorities for timely cancer diagnosis. In this study, we aimed to identify the main problems and solutions relating to delay cancer diagnosis according to cancer care clinicians.MethodsWe developed and implemented a new priority–setting approach called PRIORITIZE and invited North West London cancer care clinicians to identify and prioritize main causes for and solutions to delayed diagnosis of cancer care.ResultsClinicians identified a number of concrete problems and solutions relating to delayed diagnosis of cancer. Raising public awareness, patient education as well as better access to specialist care and diagnostic testing were seen as the highest priorities. The identified suggestions focused mostly on the delays during referrals from primary to secondary care.ConclusionsMany identified priorities were feasible, affordable and converged around common themes such as public awareness, care continuity and length of consultation. As a timely, proactive and scalable priority–setting approach, PRIORITZE could be implemented as a routine preventative system for determining patient safety issues by frontline staff.

Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study.

BackgroundMedication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care.MethodsWe used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians’ scores was presented using the average expert agreement (AEA). The study was conducted between September 2013 and November 2014.ResultsThe top three problems were incomplete reconciliation of medication during patient ‘hand-overs’, inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy. Overall, better communication between the healthcare provider and patient, quality assurance approaches during medication prescribing and monitoring, and patient education on how to use their medication were considered the top priorities. The highest ranked suggestions received the strongest agreement among the clinicians, i.e. the highest AEA score.ConclusionsClinicians identified a range of suggestions for better medication management, quality assurance procedures and patient education. According to clinicians, medication errors can be largely prevented with feasible and affordable interventions. PRIORITIZE is a new, convenient, systematic, and replicable method, and merits further exploration with a view to becoming a part of a routine preventative patient safety monitoring mechanism.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0552-6) contains supplementary material, which is available to authorized users.

We Are Not Free to Choose: Class Determinism in Zadie Smith’s NW

AbstractNW by Zadie Smith opens with a multicultural and multiracial scene and revolves around the crises in the lives of four people with longstanding connection to Northwest London. The Northwest London in NW is a besieged city, and the people therein could not see any possibility of getting out because the gate has been latched with the concept of social class. In NW, the social class is materialized as space, economic position and race. Geographically NW features the main areas of London, and considers the role of that city in shaping the consciousness of the major characters, a partly spatial configuring of identity. In addition, the major characters in NW also suffer from occupational exclusion and economic exploitation, which then lead to their lower-class position since social class is constructed in such a way that agents are distributed according to their positions in the statistical distribution based on the economic and cultural capital. Finally the racial discrimination encountered by the characters in NW shows that class relations shape the form that racial oppression takes. The racialization of class issues becomes a politically effective tool for the wealthy to divide and rule the lower classes. In NW, Smith thus has adopted a more political attitude than in her previous books, so the relatively new perspective of her fiction might be the attention she draws to the persistent obstacles to class crossing and the acknowledgment of the rigid lines that still define the social classes.