UK Healthcare Settings Research Articles

Cost-effectiveness analysis of the geko™ device (an NMES technology) in managing venous leg ulcers in UK healthcare settings.

This study evaluates the cost-effectiveness of the geko device a neuromuscular electro-stimulator technology with standard of care (SoC) versus SoC alone for venous leg ulcer (VLU) treatment, from the UK National Health Service (NHS) perspective over 12 months. Research was conducted across NHS UK facilities, primarily within community services and outpatient leg ulcer clinics, encompassing a total of 51 patients. A partitioned survival model, based on a two-arm randomised controlled trial, assessed wound healing rates using Kaplan-Meier curves and parametric extrapolations over a 12-month time horizon. Costs were derived from UK reference costs the British National Formulary, and the Personal Social Services Research Unit (2021/22). The primary outcome measured was the incremental cost per quality-adjusted life-year gained. The geko device provides additional benefits by stimulating the lateral popliteal nerve, augmenting venous, arterial, and microvascular flow. The addition of the geko device to SoC significantly enhanced outcomes, increasing healing probability by 68% compared to SoC. This integration would result in a cost saving of £774.14 per patient when compared to the SoC alone across the NHS. Economic analyses indicate that integrating the geko device into SoC protocols would reduce the overall NHS expenditure on VLU wound management by as much as 15%. The approach also positively impacted health-related quality of life. The geko™ device when used adjunctively with SoC would be a cost-effective method for managing chronic VLUs within the NHS, improving healing rates and offering economic benefits.

Implementation and barriers to waterless care: a questionnaire study of infection prevention and control practitioners, clinicians, and engineers

Water and wastewater in healthcare settings are recognized to represent a risk to patients. However, waterless care has not been widely implemented in UK healthcare settings. To identify barriers to implementation of waterless care. A questionnaire study of infection prevention and control (IPC) practitioners, non-IPC clinicians, and estates managers and engineers was undertaken. Alternatives to water present challenges in perceived acceptability to patients, particularly cleansing wipes for bathing and dry shampoo. There are concerns about cleansing wipes in terms of storage, disposal, sustainability and contamination during manufacture. Estates and engineering concerns include relative water tank size for water turnover and clinical disruption due to works. Further work is required on acceptability of reduced water scenarios and patient views but the results of this questionnaire provide a grounding for sentiment from healthcare workers on waterless care.

Effect of the ‘Pilates stance’ and Pilates-based matwork training on measurements of height, waist circumference, and interscapular distance

BackgroundStandardised guidelines for stance are used to improve interobserver reliability in anthropometric measurements in clinical practice. A key feature of the stance in Pilates is the ‘drawing in and up’ of the abdomen. The aim of this study was to study the impact of the Pilates stance on height, waist circumference and interscapular distance, compared to that recommended in clinical practice. Methods48 healthy females (median age 60 years) were assessed before and after 10-week Pilates-based matwork training. One Pilates expert and one novice took independent measurements of weight, height, waist circumference and interscapular distance (ISD). ResultsPilates stance, compared to Normal, increased height by up to 2.7 cm and decreased waist up to 5.2 cm (each P < 0.001, repeated measures ANOVA). ISD decreased up to 14 mm (P < 0.001) and this decrease was greater after training (P < 0.001). After controlling for age and length of time learning Pilates, greater baseline ISD predicted a greater change in ISD after the intervention. Effect of Pilates stance was greater when the expert took the measurements (each P ≤ 0.001). ConclusionsActivation of trunk muscles in the Pilates stance increases height and decreases waist circumference, compared to the stance recommended in UK healthcare settings. A decrease in ISD was observed, which was greater after a Pilates-based matwork programme. There are significant inter-observer differences, therefore current clinical guidelines for stance are recommended for repeated anthropometry. The value of the Pilates stance in improving posture and the role of ISD as a marker, should be further studied in various contexts, including clinical settings.

Exploration of the individual, social and environmental factors influencing dietary behaviour in shift workers with type 2 diabetes working in UK healthcare-The Shift-Diabetes Study: A qualitative study using the theoretical domains framework.

To identify factors influencing dietary behaviour in shift workers with type 2 diabetes (T2D) working in UK healthcare settings. Semi-structured qualitative interviews based on the theoretical domains framework (TDF) were conducted with a convenience sample (n = 15) of shift workers (32-59 years) diagnosed with T2D who worked night shifts as part of a mixed shift schedule. The TDF was applied to analyse transcripts using a combined deductive framework and inductive thematic analysis approach. Identified influences were mapped to the behaviour change technique taxonomy to identify potential strategies to change dietary behaviour in this context. Key barriers to healthy dietary behaviours were access and cost of food available during night work (TDF domain: Environment Context and Resources). Factors identified as both enablers and barriers included: availability of staff facilities and time to take a break, (Environment Context and Resources), the physical impact of night work (Beliefs About Consequences), eating in response to stress or tiredness (Emotion), advance planning of meals/food and taking own food to work (Behavioural Regulation). Potential techniques to address these influences and improve dietary behaviour in this context include: meal planning templates, self-monitoring and biofeedback, and increasing accessibility and availability of healthier food choices during night shifts. The dietary behaviour of shift workers with T2D is influenced by interacting individual, socio-cultural and environmental factors. Intervention should focus on environmental restructuring and strategies that enable monitoring and meal planning.

Individual, social and environmental factors influencing dietary behaviour in shift workers with type 2 diabetes working in UK healthcare: A cross-sectional survey.

The present study aimed to understand the individual, social and environmental factors influencing dietary behaviour in shift workers with type 2 diabetes (T2D) working in UK healthcare settings. A cross-sectional study was conducted using data collected from an anonymous online survey. Participant agreement was measured using five-point Likert scale (strongly disagree to strongly agree) against 38 belief statements informed by the Theoretical Domains Framework (TDF) of behaviour change. From the complete responses (n = 119), 65% worked shifts without nights, 27% worked mixed shift rota including nights and 8% worked only night shifts. The statements ranked with the highest agreements were in the TDF domains: Environment Context/Resources (ECR) - mainly identified as a barrier to healthy eating, Behaviour Regulation (BR) and intention (IN) - identified as enablers to healthy eating. For the belief statement 'the available options for purchasing food are too expensive' (ECR), 80% of night workers and 75% non-night workers agreed/strongly agreed. Taking their own food to work to prevent making unhealthy food choices (BR) had agreement/strong agreement in 73% of non-night and 70% night workers; 74% non-night workers and 80% of night workers agreed/strongly agreed with the statement 'I would like to eat healthily at work' (IN). Mixed shift workers agreed that following dietary advice was easier when working a non-night compared to a night shift (p = 0.002). Access and affordability of food were identified as important determinants of dietary behaviour during shifts. The findings support interventions targeting the food environment for shift workers with T2D.

The value of blood-based measures of liver function and urate in lung cancer risk prediction: A cohort study and health economic analysis

BackgroundSeveral studies have reported associations between low-cost blood-based measurements and lung cancer but their role in risk prediction is unclear. We examined the value of expanding lung cancer risk models for targeting low-dose computed tomography (LDCT), including blood measurements of liver function and urate. MethodsWe analysed a cohort of 388,199 UK Biobank participants with 1873 events and calculated the c-index and fraction of new information (FNI) for models expanded to include combinations of blood measurements, lung function (forced expiratory volume in 1 s - FEV1), alcohol status and waist circumference. We calculated the hypothetical cost per lung cancer case detected by LDCT for different scenarios using a threshold of ≥ 1.51 % risk at 6 years. ResultsThe c-index was 0.805 (95 %CI:0.794–0.816) for the model containing conventional predictors. Expanding to include blood measurements increased the c-index to 0.815 (95 %CI: 0.804–0.826;p < 0.0001;FNI:0.06). Expanding to include FEV1, alcohol status, and waist circumference increased the c-index to 0.811 (95 %CI: 0.800–0.822;p < 0.0001;FNI: 0.04). The c-index for the fully expanded model containing all variables was 0.819 (95 %CI:0.808–0.830;p < 0.0001;FNI:0.09). Model expansion had a greater impact on the c-index and FNI for people with a history of smoking cigarettes relative to the full cohort. Compared with the conventional risk model, the expanded models reduced the number of participants meeting the criteria for LDCT screening by 15–21 %, and lung cancer cases detected by 7–8 %. The additional cost per lung cancer case detected relative to the conventional model was £ 1018 for adding blood tests and £ 9775 for the fully expanded model. ConclusionBlood measurements of liver function and urate made a modest improvement to lung cancer risk prediction compared with a model containing conventional risk factors. There was no evidence that model expansion would improve the cost per lung cancer case detected in UK healthcare settings.

Serum biomarkers identify critically ill traumatic brain injury patients for MRI

BackgroundMagnetic resonance imaging (MRI) carries prognostic importance after traumatic brain injury (TBI), especially when computed tomography (CT) fails to fully explain the level of unconsciousness. However, in critically ill patients, the risk of deterioration during transfer needs to be balanced against the benefit of detecting prognostically relevant information on MRI. We therefore aimed to assess if day of injury serum protein biomarkers could identify critically ill TBI patients in whom the risks of transfer are compensated by the likelihood of detecting management-altering neuroimaging findings.MethodsData were obtained from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Eligibility criteria included: TBI patients aged ≥ 16 years, Glasgow Coma Score (GCS) < 13 or patient intubated with unrecorded pre-intubation GCS, CT with Marshall score < 3, serum biomarkers (GFAP, NFL, NSE, S100B, Tau, UCH-L1) sampled ≤ 24 h of injury, MRI < 30 days of injury. The degree of axonal injury on MRI was graded using the Adams-Gentry classification. The association between serum concentrations of biomarkers and Adams-Gentry stage was assessed and the optimum threshold concentration identified, assuming different minimum sensitivities for the detection of brainstem injury (Adams-Gentry stage 3). A cost–benefit analysis for the USA and UK health care settings was also performed.ResultsAmong 65 included patients (30 moderate-severe, 35 unrecorded) axonal injury was detected in 54 (83%) and brainstem involvement in 33 (51%). In patients with moderate-severe TBI, brainstem injury was associated with higher concentrations of NSE, Tau, UCH-L1 and GFAP. If the clinician did not want to miss any brainstem injury, NSE could have avoided MRI transfers in up to 20% of patients. If a 94% sensitivity was accepted considering potential transfer-related complications, GFAP could have avoided 30% of transfers. There was no added net cost, with savings up to £99 (UK) or $612 (US). No associations between proteins and axonal injury were found in intubated patients without a recorded pre-intubation GCS.ConclusionsSerum protein biomarkers show potential to safely reduce the number of transfers to MRI in critically ill patients with moderate-severe TBI at no added cost.

NS-65: Introducing frailty assessment into a myeloma service – a Quality Improvement Project (QIP)

Developments in management and treatment of myeloma have extended survival rates in the myeloma population (Kumar et al, 2008) resulting in older patients living with the effects of myeloma and treatments and also the concurrent problems of ageing. The myeloma multidisciplinary team (MDT) in Leicester UK introduced frailty assessment for newly diagnosed patients over 65 years using QIP methodology as a Clinical Nurse Specialist (CNS) led initiative. The aim being to improve MDT decision making and documentation about treatment attenuation and furthermore to proactively identify frailty to enable enhanced support for frailer patients. This was aimed to be the initial development of an older person's pathway of care. The International Myeloma Working Group (IMWG) frailty score (Palumbo et al 2015) and Clinical Frailty Score (Rockwood et al, 2005) were used as assessment tools, the latter being widely used throughout UK healthcare settings. Following initial audit and project planning, stakeholder engagement was undertaken using questionnaires, experience surveys and presentations. Interventions were planned using the Plan-Do-Study-Act (PDSA) method. Data was collected via audit of a number of team documentation sources and via patient feedback questionnaires. The aim of the project was surpassed and in both PDSA 2 and 3, 100% of newly diagnosed patients were frailty assessed, results being discussed in MDT, documented and communicated to primary care. The quality of information about patient frailty and function assisted MDT decision-making processes and improved over the QIP. This enabled clear rationales for MDT decisions to be documented in relation to individualised patient treatment options. There were no extra demands on CNS time, in fact consultation time decreased. Patient experience was maintained. The MDT recognised during the project that frailty scores need to be used with caution taking into consideration myeloma burden and presenting complications to avoid the risk of under-treatment (American Society of Haematology, 2019). Frailty scoring is now embedded into practice and assessment.

Exploring the impacts of organisational structure, policy and practice on the health inequalities of marginalised communities: Illustrative cases from the UK healthcare system

This paper explores how organisational structure, policies and practices in healthcare can inadvertently disadvantage marginalised populations (e.g. individuals from ethnic minority backgrounds) and reinforce health inequalities. We draw upon three diverse UK healthcare settings (long term care institutions, high security hospitals and community pharmacies) to illustrate how systemic injustices negatively impact on access to care, treatment and health outcomes. The first case study considers the care of older people within nursing homes; specifically the disempowering effects of this service structure and impacts of choice reduction upon health and their access to health provision. The second case study explores the impact of security restrictions upon patients within high security hospitals, focusing particularly on the maintenance of relationships and support networks outside of the hospital. The third and final case study, draws upon a national community pharmacy medicine management service to illustrate ways in which policies and guidelines inadvertently obstruct patients' engagement with the service within a community setting. We draw upon these settings to highlight inequalities within different contexts and to illustrate the ways in which well intended services can inadvertently disadvantage marginalised communities in multiple ways.

A patient-reported pressure ulcer health-related quality of life instrument for use in prevention trials (PU-QOL-P): psychometric evaluation

IntroductionPressure ulcer-specific patient-reported outcome (PRO) instruments should be used to inform patient care and provide a strong evidence base for interventions aimed at preventing pressure ulcers. The aim was to carry out a comprehensive evaluation of the psychometric properties of a PRO instrument designed to assess symptoms and functional outcomes in patients at high-risk of developing pressure ulcers, the PU-QOL-P instrument.MethodsWe modified the original PU-QOL instrument to be suitable for patients at high risk of pressure ulcer development based on feedback from patients, specialist nurses and PRO methodologists. The modified PU-QOL-P instrument was administered to a sub-set of patients participating in the PRESSURE 2 trial. Patients completed PU-QOL-P and SF12 instruments at baseline, weeks 1 and 3, and 30 days post-treatment. We undertook psychometric evaluation of the modified PU-QOL-P to test scale targeting, scaling assumptions, reliability, validity and responsiveness.ResultsThe analysis sample consisted of 617 patients that completed both instruments at baseline. We found that the PU-QOL-P instrument, consisting of nine PU-specific outcomes: three symptom and six function scales, meets established criteria for reliability, construct validity, and responsiveness. Internal consistency reliability was high with all scale Cronbach alpha > 0.795 (range 0.795–0.970). The factor analysis mostly supported the six-function scale structure. Scaling assumptions were satisfied; all item-total correlations above 0.30. Convergent validity was confirmed by significant correlations between hypothesized scales as expected. PU-QOL-P scales were responsive to change: mean scale scores from baseline to 30 days post-treatment were statistically significant for all scales apart the daily activities scale (effect sizes ranged from moderate to high). As expected, worse symptoms and functioning was observed in patients who had a category 1 or 2 PU compared to patients who did not have a PU.ConclusionsThe PU-QOL-P provides a standardised method for assessing pressure ulcer-specific symptoms and functional outcomes for quantifying the benefits of associated interventions from the patient’s perspective. It can be used in research with adults at risk of pressure ulcer development in all UK healthcare settings.

Gram-negative blood stream infections - challenges and improvement plans in the UK

Introduction: Blood stream infection caused by E.coli and other gram negative infections has been steadily rising in the UK alongside reductions in other infections like MRSA. The UK regulator NHS Improvement has been tasked by the Minister of State for Health to reduce E.coli bacteraemia by 50% by 2021. This poster/presentation will describe the extent of the problem and discuss initiatives being used in UK communities, hospitals and healthcare settings to bring E.coli bacteraemia numbers under control

The survivability of dialectical behaviour therapy programmes: a mixed methods analysis of barriers and facilitators to implementation within UK healthcare settings

BackgroundDialectical Behaviour Therapy (DBT) is an evidence-based intervention that has been included in the National Institute of Health and Care Excellence guidelines as a recommended treatment for Borderline Personality Disorder in the UK. However, implementing and sustaining evidence-based treatments in routine practice can be difficult to achieve. This study compared the survival of early and late adopters of DBT as well as teams trained via different training modes (on-site versus off-site), and explored factors that aided or hindered implementation of DBT into routine healthcare settings.MethodsA mixed-method approach was used. Kaplan-Meier survival analyses were conducted to quantify and compare survivability as a measure of sustainability between early and late implementers and those trained on- and off-site. An online questionnaire based on the Consolidated Framework for Implementation Research was used to explore barriers and facilitators in implementation. A quantitative content analysis of survey responses was carried out.ResultsEarly implementers were significantly less likely to survive than late implementers, although, the effect size was small. DBT teams trained off-site were significantly more likely to survive. The effect size for this difference was large. An unequal amount of censored data between groups in both analyses means that findings should be considered tentative. Practitioner turnover and financing were the most frequently cited barriers to implementation. Individual characteristics of practitioners and quality of the evidence base were the most commonly reported facilitators to implementation.ConclusionsA number of common barriers and facilitators to successful implementation of DBT were found among DBT programmes. Location of DBT training may mediate programme survival.

Peer influence as a driver of technological innovation in the UK National Health Service: a qualitative study of clinicians’ experiences and attitudes

BackgroundAccelerating innovation to improve quality is a key policy target for healthcare systems around the world. Effectively influencing individuals’ behaviour is crucial to the success of innovation initiatives. This study...

Impact of the national rotavirus vaccination programme on acute gastroenteritis in England and associated costs averted

BackgroundIntroduction of infant oral rotavirus vaccination in the UK in July 2013 has resulted in decreased hospitalisations and Emergency Department (ED) visits for acute gastroenteritis (AGE), for both adults and children. We investigated reductions in AGE incidence seen in primary care in the two years after vaccine introduction, and estimated the healthcare costs averted across healthcare settings in the first year of the vaccination programme. MethodsWe used primary care data from the Clinical Practice Research Datalink and age-stratified time-series analyses to derive adjusted incidence rate ratios (IRRa) for AGE in the first two years of the post-vaccination era (July 2013-April 2015) compared to the pre-vaccination era (July 2008-June 2013). We estimated cases averted among children aged <5years in the first year of the vaccination programme by comparing observed numbers of AGE cases in 2013–2014 to numbers predicted from the time-series models. We then estimated the healthcare costs averted for general practice consultations, ED visits and hospitalisations. ResultsIn general practice, AGE rates in infants (the target group for vaccination) decreased by 15% overall after vaccine introduction (IRRa=0.85; 95%CI=0.76–0.95), and by 41% in the months of historically high rotavirus circulation (IRRa=0.59; 95%CI=0.53–0.66). Rates also decreased in other young children and to a lesser degree in older individuals, indicating herd immunity. Across all three settings (general practice, EDs, and hospitalisations) an estimated 87,376 (95% prediction interval: 62,588–113,561) AGE visits by children aged <5years were averted in 2013–14, associated with an estimated £12.5million (9,209–16,198) reduction in healthcare costs. ConclusionsThe marked decreases in the general practice AGE burden after rotavirus vaccine introduction mirror decreases seen in other UK healthcare settings. Overall, these decreases are associated with substantial averted healthcare costs.

Cost analysis of standard Sanger sequencing versus next generation sequencing in the ICONIC study

BackgroundHIV and hepatitis C virus (HCV) are a major cause of morbidity and mortality, and both viruses contain high genomic variation. To date, viral gene sequencing has been handled by standard Sanger sequencing (SSS) for the detection of specific drug-resistance determinants for HIV and HCV. However, SSS-derived information is very limited. By contrast, full-length viral gene sequences when linked to clinical data might influence the monitoring of drug resistance to optimally guide treatment, identify sources of viral transmissions within health-care settings, and track emerging epidemics. The ICONIC (Infection Response through Virus Genomics) study aims to introduce a novel method called next generation sequencing (NGS) within UK health-care settings, testing potential implementation in routine practice. With use of samples within established diagnostic laboratory workflows, NGS has the potential to produce higher informational content than SSS and report in a timely fashion. However, economic evidence for this emerging method is scarce. We aimed to use the examples of HIV and HCV to compare the cost of NGS versus SSS. MethodsWe performed a bottom-up cost analysis using published, genomic-testing, costing templates to estimate the mean cost per sample for SSS and NGS methods over a 1 year period at a major London hospital. Data on resource use associated with genomic testing were based on estimates from individual sample data, routinely collected from a UK population. FindingsWith SSS, mean cost per sample, including operating costs, was £178 for HCV (2080 samples) and £79 for HIV (520). Mean cost per sample with NGS was £119 (2207 samples), including operating costs, generating a cost saving of £59 for HCV and a surplus of £40 for HIV. Although this method is still research based and prices vary widely, our results demonstrated a broad NGS and SSS cost equivalence. InterpretationNGS is data rich and could be integrated in emerging stratified patient treatments. The mean cost per sample for the two methods should be similar and provide added-value information. A number of costing toolkits should be designed to address the appropriate pricing, including health-care consultation and operating costs when considering NGS efficiency and cost-effectiveness. The mean cost per sample for NGS as part of routine health care requires further exploration. FundingThis project is funded by the Health Innovation Challenge Fund, a parallel partnership between the Wellcome Trust and the Department of Health (ref HICF-T5-344). FRB received funding for this study from the National Institute for Health Research (NIHR) Biomedical Research Centre, and the UCLH/UCL Biomedical Research Centre funded this NIHR Health Informatics Collaborative study.

Causal study of low stakeholder engagement in healthcare simulation projects

Stakeholder engagement plays a fundamental role in the success of ‘operational research’ initiatives including simulation projects. However, there is little empirical evidence of real engagement in the context of healthcare simulation. This paper principally examines this issue and aims to provide insights into the possible causes. The paper reports on the results of a literature review and 10 field studies within the UK healthcare settings, supplemented with the authors’ experience in order to arrive at an initial list of the causes, which will then be tested through a survey of expert opinions. Twelve primary and 26 secondary causal factors, which received statistically significant level of agreement from the experts, are presented in a fish-bone diagram. The findings indicate that communication gap between simulation and stakeholder groups is the top primary factor contributing the most to the poor stakeholder engagement in healthcare simulation projects, followed by ‘poor management support’, ‘clinician’s high workload’ and ‘failure in producing tangible and quick results’.

Exploration of cultural competency training in UK healthcare settings: A critical interpretive review of the literature

Cultural competency training (CCT) has been proposed as a strategy for eliminating racial inequalities and ensuring culturally appropriate services. However the literature illustrates inconsistencies in the usage, understanding and implementation of cultural competency training. The study aimed to understand how cultural competency training is conceptualised in UK healthcare settings, through a critical interpretive review of the literature. The search strategy involved the use of five electronic databases, supplemented by citation tracking, consultation with academic experts and library searches. Of 748 papers, 36 satisfied the inclusion and exclusion criteria. Critical interpretive synthesis (CIS) was used to analyse these papers. The study design assimilated methods adopted in conventional systematic reviews within the format of CIS, to combine the entire body of literature and generate theoretical categories. Two synthetic constructs (overarching themes) were produced from the analysis; ‘conflicting concepts’ and ‘incongruence between theory and practice’. Together these constructs generated an outlined theoretical framework (‘synthesising argument’) defined as ‘institutional commitment’ towards CCT, which collectively explained the findings of the review. ‘Institutional commitment’ provided an explanation for the inconsistencies in the practice of CCT. It illustrated the internal tensions towards those actively committed to CCT versus those who are not and the lack of institutional buy-in to the concept and practice of CCT throughout the healthcare system.

Compassion in healthcare - lessons from a qualitative study of the end of life care of people with dementia.

A lack of compassion in UK healthcare settings has received much recent attention. This study explores the experiences of people with dementia in the last year of life and time surrounding death and how the presence and lack of compassion, kindness and humanity influenced the experience of care. Qualitative in-depth interviews with bereaved informal carers of people with dementia. United Kingdom. Forty bereaved carers - 31 women and nine men - with an age range of 18-86 years and from wide socioeconomic backgrounds participated. Experiences of carers of care for person with dementia during last year of life. The interviews highlighted differences and challenges in care settings in providing compassionate, humanistic care and the impact of the care experienced by the person with dementia during the last year of life on informal carers during the bereavement period and beyond. Excellent examples of compassionate care were experienced alongside very poor and inhumane practices. The concepts of compassion, kindness and humanity in dementia care are discussed within the paper. The ability to deliver care that is compassionate, kind and humanistic exists along a continuum across care settings - examples of excellent care sit alongside examples of very poor care and the reasons for this are explored together with discussion as to how health and social care staff can be trained and supported to deliver compassionate care.

Bringing Anglo-Governmentality into Public Management Scholarship: The Case of Evidence-based Medicine in UK Health Care: Table 1

The field of public administration and management exhibits a limited number of favored themes and theories, including influential New Public Management and Network Governance accounts of contemporary government. Can additional social science–based perspectives enrich its theoretical base, in particular, analyzing a long-term shift to indirect governance evident in the field? We suggest that a variant of Foucauldian analysis is helpful, namely “Anglo-governmentality.” Having reviewed the literatures, we apply this Anglo-governmentality perspective to two case studies of “post hierarchical” UK health care settings: first, the National Institute for Health and Clinical Excellence (NICE), responsible for producing evidence-based guidelines nationally, and the second, a local network tasked with enacting such guidelines into practice. Compared with the Network Governance narrative, the Anglo-governmentality perspective distinctively highlights (a) a power–knowledge nexus giving strong technical advice; (b) pervasive grey sciences, which produce such evidence-based guidelines; (c) the “subjectification” of local governing agents, herein analyzed using Foucauldian concepts of the “technology of the self” and “pastoral power”; and (d) the continuing indirect steering role of the advanced neoliberal health care State. We add to Anglo-governmentality literature by highlighting hybrid “grey sciences,” which include clinical elements and energetic self-directed clinical–managerial hybrids as local governing agents. These findings suggest that the state and segments of the medical profession form a loose ensemble and that professionals retain scope for colonizing these new arenas. We finally suggest that Anglo-governmentality theory warrants further exploration within knowledge-based public organizations.

Respecting dignity in care in diverse care settings: Strategies of UK nurses

This paper presents nurses' views of dignity issues in diverse UK health-care settings. A qualitative multisite case study was conducted at seven organizations: four National Health Service hospitals, two independent care providers and one mental health-care provider. The paper reports on the data from qualitative semistructured interviews (n = 51); the participants worked in a wide variety of care contexts. The data were analysed thematically and this paper reports on the theme 'strategies to respect dignity in care'. The subthemes were: recognizing vulnerability to dignity loss; enhancing privacy; improving communication between staff and patients/families and building relationships; improving the care environment; and addressing issues that matter to individuals. The findings indicate core elements to promoting dignity that apply across all care settings but suggest that nurses should identify and address dignity issues specific to their own practice areas.