UK Midlands Research Articles

Brexit, trade and UK advanced manufacturing sectors: a Midlands’ perspective

ABSTRACT The paper examines how Brexit has impacted on Original Equipment Manufacturers (OEMs) and suppliers in the UK Midlands, and to what extent such firms are reconfiguring their supply chains with the increase in trade barriers with Brexit. To do this, the paper aims to add to macro studies in the area by using a mixed-methods approach that combines descriptive quantitative analysis of secondary data with a complementary qualitative research analysis based on a novel interview dataset. The latter is generated from 14 semi-structured interviews conducted in late 2021 with senior managers and directors in advanced manufacturing firms across the East and West Midlands regions of the UK. A key finding of this paper is that the imposition of new non-tariff barriers through Brexit has proved particularly challenging to smaller firms in manufacturing supply chains. The findings of our research highlight the need for policy support for smaller firms engaging in EU-wide supply chains, particularly around skillsets and access to talent, cost reduction for exports and facilitating trade.

Conflicting experiences of health and habitus in a poor urban neighbourhood: A Bourdieusian ethnography.

An ethnographic study of health and wellbeing was undertaken in a deprived urban neighbourhood in the UK Midlands. Drawing on Bourdieu's concepts of habitus, capital and field, we discerned three different, even conflicting, ways of understanding and acting on health: (i) older adults discussed their wellbeing in relation to the local context or field, walking the dog, helping at the community centre and visiting the off licence, (ii) young professionals and students who lived in the neighbourhood were oriented towards leisure facilities, career opportunities and supermarkets outside of the neighbourhood, disdaining local facilities and (iii) community activists and carers discussed health in terms of providing for others but not themselves. Bourdieu is frequently used in medical sociology to highlight how poor people's lifestyle is constrained by their habitus; we suggest paying more attention to its both enabling and differentiating contradictions as well as the constraints it entails. Empirically and in terms of health promotion findings suggest that supposedly healthy activities, such as going to the gym, may also be a means of rejecting the local community; similarly, older people's pottering about in the neighbourhood, which is not usually recognised as a healthy activity, may enhance wellbeing in this context.

Factors influencing the selection of a procurement route for UK off-site housebuilding

While there is a plethora of research into the perceived benefits of off-site construction systems and the barriers towards their adoption, there has been very little discussion of the procurement route selection factors for off-site residential projects in the UK Midlands region. This study sought to identify the factors that influence the selection of a procurement method for off-site housebuilding projects in the Midlands. The aim of the paper was to identify the critical factors influencing the procurement selection for off-site housebuilding developments through a survey of 157 construction professionals and housing developers using the relative importance index as a basis for analysis. A comparison between the most highly ranked factors for off-site manufacturing and those presented in the literature indicates that practitioners’ perceptions are largely aligned with those of traditional construction processes. The higher constructability of design and environmental sustainability have been shown to have a greater influence on the selection of the most appropriate procurement route for off-site housebuilding as compared to those applicable to traditional construction. The research findings can also help practitioners to develop a wider and deeper perspective of the criteria for selecting the appropriate procurement method for off-site residential projects at a regional level.

Understanding and improving decision-making around referral and admissions to intensive care: a mixed methods study

Background: Intensive care treatment can be life-saving but is invasive and distressing for patients receiving them, and not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge. Objectives: To explore the decision-making process around referral and admission to ICU and develop an intervention to improve it. Methods: A mixed methods study including: a) Two systematic reviews investigating factors associated with decisions to admit to an intensive care unit (ICU) and experiences of clinicians, patients and families of the process. b) A focused ethnographic study including observation of decisions and interviews with ICU doctors, referring doctors, patients and families in six NHS Trusts in the UK Midlands. 55 decisions regarding 46 patients were observed. 101 doctors were interviewed. c) A Choice Experiment questionnaire survey with paired patient profiles developed using data from the ethnographic study and systematic reviews. UK ICU consultants and Critical Care Outreach Nurses were invited to participate. Participants’ preferences for ICU admission were analysed using a Random Utility Framework and preference heterogeneity using a latent class logit (LCL) model. d) Using the data from systematic reviews, ethnographic study and CE we developed a Decision Support Intervention (DSI) including an ethical framework for decision-making, guidance for referral and supporting referral and decision support forms and patient and family information leaflets. It was tested for implementation feasibility in three NHS Trusts purposively sampled for size of ICU. An eight week implementation period was followed by six weeks data collection. Quantitative and qualitative data were collected to evaluate form usage, intervention acceptability, barriers and facilitators to implementation, and impact on decisionmaking. e) A tool to evaluate the ethical quality of decision-making related to ICU admission was developed, based on assessment of patient records. The tool was tested for inter-rater and inter-site reliability in 120 patient records across the three sites in the implementation feasibility study. Results: Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of DNACPR order, referring specialty, referrer seniority, and ICU bed availability. ICU doctors used a gestalt assessment of the patient in making decisions. The CE showed age was the most important factor in consultant and CCOR nurses preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, the importance of inter-professional relationships, and good communication between teams and with patients and families. Doctors find it difficult to articulate and balance benefits and burdens of ICU treatment for a patient. There was low uptake of the DSI although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients. Several challenges were identified in developing an evaluation tool.

REMOVAL OF DISSOLVED METHANE AND OTHER CONTAMINANTS FROM LANDFILL LEACHATES IN ENGINEERED WETLANDS

This paper will present detailed design and operational data for a full-scale horizontal flow reed bed system, specifically designed for removal of dissolved methane from leachates at a closed landfill in the UK Midlands, near to the city of Birmingham. Since commissioning during the summer of 2013, as reeds have grown, extensive operational data have demonstrated successful and complete removal of dissolved methane to below required concentrations, for safe disposal into the public sewer. The Shirley reed bed is very successful at removing high initial levels of dissolved methane (>95% removal), as per the intended requirements. This ensures that methane within the discharged effluent remains below the 0.14mg/l consent concentration. Removal of methane has been achieved consistently for over 5 years from summer 2014 despite occasional increases in leachate flow rates above the design capacity for the reed bed. Additional removal of further contaminants is achieved by the reedbed, where the successful removal of high levels of iron and suspended solids from the leachate is observed. Monitoring has also noted significant seasonal nitrification of ammoniacal-N, although this was not part of the original purpose of the bed. Design, operational and monitoring data are presented and discussed, with discussion of how various practical issues were overcome during the six years of operation. The technology has wide application for many closed landfill sites throughout the world, and design loading data have been derived that will be valuable for operators to size reed beds appropriately at their sites.

Home-owned versus foreign-owned firms in the UK automotive industry: Exploring the microfoundations of ambidextrous production and supply chain positioning

The UK automotive industry is home to a large number of foreign firms, demonstrating the open nature of competition. However, the industry necessitates both exploitative and explorative capabilities. Contingency theory suggests that firms align their internal structure with contextual factors. As such, the aims of this study were to investigate whether it was possible to distinguish home-owned (UK) and foreign-owned firms based upon: a) the microfoundations of ambidextrous production, which are conceptualised as lean and agile routines; and b) the tier at which these firms operate in the automotive supply chain. Survey data were collected from 85 home-owned and 55 foreign-owned firms within the UK Midlands automotive industry. Logistic regression results revealed that home-owned firms were significantly more likely to be implementing explorative (agile) production methods, whereas foreign-owned firms were significantly more likely to be implementing exploitative (lean) production. Home-owned and foreign-owned firms were found to be significantly more likely to be operating upstream and downstream in the automotive supply chain respectively. Thus, the findings support a contingency theory explanation, suggesting that firms align their performance priorities with contextual factors, but we argue that home-owned and foreign-owned firms have evolved to compete based on their different innovative capabilities, which are located at different tiers of the automotive supply chain. On this basis, although neither home-owned nor foreign-owned firms were found to be endogenously ambidextrous, we argue that foreign-owned firms internationalise into the UK automotive sector to exploit the explorative capabilities acquired by home-owned firms operating upstream in automotive supply chains, thus enabling ambidextrous capabilities at an exogenous, industrial level.

Abstract P-064: NOT JUST A TEAM LEADER - CREATING THE IDEAL TRANSPORT TEAM

Aims & Objectives: To improve the training of team leaders on a regional retrieval team to better support their nursing colleagues. Methods KIDS/NTS is a regionalized, paediatric and neonatal intensive care retrieval and transport service based in the UK Midlands, transporting around 1,800 infants/children annually. KIDS (paediatric team) train 10–15 doctors and 8–10 nurses annually to transport critically ill infants/children. The team is usually comprised of a team leader (Consultant/Advanced Nurse Practitioner (ANP)/Registrar/Clinical Fellow), a nurse and an ambulance technician. Anecdotal feedback from KIDS nurses suggested differences in team leadership depending on the discipline of the team leader affected their stress levels. To understand this, all KIDS/NTS nurses (n=25) were surveyed (Figure 1).Results Response rate was 48%. The discipline of the team leader was identified in 66.7% of responses as affecting stress levels with 58.3% preferring ANP’s as team leader. Familiarity with the nurse’s role was identified as a reason for this preference in 91.7% of respondents, as was transport experience for 75% of respondents. 66.7% felt that spending more time with retrieval nurses and 58.3% a more structured supernumerary period would be beneficial to training. Lack of familiarity with the ‘transport process’ was also cited as a stressor. Conclusions A key factor to stress levels experienced by nurses on the team was shown to be familiarity of the nurse’s roles. The survey findings have been used to redesign training to narrow the gap between disciplines. All new team leaders are now trained by core ANP’s and time is allocated to work alongside retrieval nurses.

Abstract PCCLB-11: TO MERGE OR NOT TO MERGE………… IS IT POSSIBLE TO MERGE 2 WELL ESTABLISHED TRANSPORT TEAMS SUCCESSFULLY?

Aims & Objectives: To successfully merge 2 well established transport teams whilst maintaining efficiency and ensuing no extra financial burden. The outcome was to provide an improved patient journey. Introduction- KIDS/NTS is a regionalized, paediatric and neonatal intensive care retrieval service based at Birmingham Children’s Hospital (BCH) in the UK Midlands, transporting around 1,800 babies/children annually. Prior to July 2016 the KIDS (paediatric) and NTS (neonatal) teams worked independently of each other in the West Midlands region of the UK, with little or no cross working. A project was undertaken to scope the feasibility of merging 2 established transport teams to work together as one.Methods The process was a long one, involving 2 scoping episodes. Once the request to merge came from the commissioners, the teams held joint away days to work through the practical aspects of merging. Results On 01/07/2016 2 clinical teams started to work out of 1 operations centre, with 1 freephone telephone number, 1 administration and 1 ambulance team. It remained ‘business as usual’ with both teams operating independently, although collaboration between the teams began to develop. Throughout 2017 the nursing teams became more integrated with a restructuring of the nursing leadership leading to some cross covering of nursing shifts. Team leaders and specialty consultant cover remain separate. Conclusions With careful planning and empathy for the potential destabilising effects on the teams involved it is possible to successfully merge 2 well established teams. Away days and maintaining a climate of mutual respect for each other have been key to the success.

Opioid prescribing for chronic musculoskeletal pain in UK primary care: results from a cohort analysis of the COPERS trial

ObjectiveTo establish the level of opioid prescribing for patients with chronic musculoskeletal pain in a sample of patients from primary care and to estimate prescription costs.DesignSecondary data analyses from a...

The dynamical impact of Rossby wave breaking upon UK PM<sub>10</sub> concentration

Abstract. Coarse particulate matter (PM10) has long been understood to be hazardous to human health, with mortality rates increasing as a result of raised ground level concentrations. We explore the influence of synoptic-scale meteorology on daily mean observed PM10 concentration ([PM10]) using Rossby wave breaking (RWB). Meteorological reanalysis data for the winter months (DJF) between January 1999 and December 2008 and observed PM10 data for three urban background UK (Midland) sites were analysed. Three RWB diagnostics were used to identify RWB that had significant influence on UK Midland PM10. RWB events were classified according to whether the RWB was cyclonic or anticyclonic in its direction of breaking and whether the RWB event was influenced more by poleward or equatorial air masses. We find that there is a strong link between RWB events and UK [PM10]. Significant increases (p < 0.01) in UK [PM10] were seen 1 day following RWB occurring in spatially constrained northeast Atlantic–European regions. Analysis into episodic PM10 exceedance events shows increased probability of [PM10] exceedance associated with all RWB subsets. The greatest probability of exceeding the UK [PM10] threshold was associated with cyclonic RWB preceded by anticyclonic RWB forming an Ω block synoptic pattern. This mechanism suggests an easterly advection of European PM10 followed by prolonged stagnant conditions within the UK and led to an almost threefold increase in the probability of the UK Midlands exceeding a hazardous [PM10] threshold (0.383), when compared to days where no RWB was detected (0.129).

Time‐use and well‐being impacts of travel‐to‐work and travel‐for‐work

This article contributes to our understanding of the complex patterns of travel‐to‐work and travel‐for‐work which increasingly characterise highly skilled employment, using 2015 data from a UK Midlands study comprising an online survey and follow‐up interviews. Travel‐to‐work essentially lengthens the working day, and is difficult to use productively, especially when commuting by car. Travel‐for‐work, by contrast, results in intense schedules especially when requiring overnight stays. Ownership of travel‐for‐work is ambiguous: it is employer driven, and travel time is often spent productively using mobile technologies, but is rarely rewarded with TOIL. While general dissatisfaction is reported with the commute, negative effects of travel‐for‐work (family, health, reduced leisure time) are mediated by positive impacts including experience of new working cultures, and infrequency of travel. Four factors appear central to the differing well‐being impacts: (1) frequency of travel; (2) ability to plan travel; (3) productive use of travel time, and; (4) reciprocal benefits of travel.

Predominance of enterovirus B and echovirus 30 as cause of viral meningitis in a UK population

Background/ObjectivesEnteroviruses are the most common cause of aseptic or lymphocytic meningitis, particularly in children. With reports of unusually severe neurological disease in some patients infected with enterovirus D68 in North America, and a recent increase in the number of paediatric enterovirus meningitis cases presenting in this UK Midlands population, a retrospective regional surveillance study was performed. Study designCerebrospinal fluid (CSF) samples received were tested using the polymerase chain reaction (PCR) for HSV-1/2, VZV, enteroviruses and parechoviruses. Enterovirus PCR positive CSF samples were sent for further serotyping. A phylogenetic tree was constructed of the echovirus 30 VP1 sequences, where sufficient sample remained for sequencing. ResultsThe number of enterovirus positive CSFs from each year were: 21 (2008), 7 (2011), 53 (2012), 58 (2013) and 31 (2014). Overall, 163 of the 170 serotyped enteroviruses belonged to the species B (echovirus 5, 6, 7, 9, 11, 13, 16, 17, 18, 21, 25, 30; coxsackie B1, B2, B3, B4, B5, A9), with only 7 belonging to species A (coxsackie A2, A6, A16 and enterovirus 71). Echovirus 30 was the predominant serotype overall, identified in 43 (25.3%) of samples, with a significantly higher proportion in the adult age group (37.3%) compared to the infant age group (12.3%). Phylogenetic analysis showed that these UK Midlands echovirus 30 VP1 sequences clustered most closely with those from Europe and China. ConclusionThis study showed a continued predominance of echovirus 30 as a cause of viral meningitis, particularly in adults, though more surveillance is needed.

Potential for further reduction in the embodied carbon in PV solar energy systems

In this study the potential for further reduction in greenhouse gas emissions (GHG) of c-Si, multi-crystalline silicon (mc-Si) and CdTe photovoltaic (PV) systems are assessed to inform climate change mitigation in the UK. The amount of CO2 equivalent released in grams for each kWh of electricity over the lifetime of the PV system (gCO2-e/kWh) has been assessed using a model to predict the change in GHG as a result of engineering improvements in the PV module and system operation. The scenarios modelled here are for two different locations in the UK (Midlands and South West England) to give a typical range. Similarly a range of carbon intensity in manufacture is considered by taking manufacture in China and the UK. This study considers the impact of; system and inverter lifetimes, continuing trends of increases in module conversion efficiencies and reduction in carbon intensity during manufacture. For most of the scenarios considered the extension of the PV system lifetime to 40 years makes the largest impact while extending inverter lifetime for deployment of thin film PV modules becomes more significant and cannot be ignored. All of the four interventions considered in this study can significantly contribute to a reduction in the carbon footprint of PV by the near term target of 2020. For all three module systems considered the model shows the potential for the carbon footprint to be reduced to one third of the 2012 values giving a range of 11–38 gCO2-e/kWh, which is within the range of current wind generation in the UK.

The epidemiology of common respiratory viruses in a UK Midlands population, 2010–2014

The epidemiology of common respiratory viruses in a UK Midlands population, 2010–2014

Practical compassions: repertoires of practice and compassion talk in acute mental healthcare

This article reports an exploratory study of the concept of compassion in the work of 20 mental health practitioners in a UK Midlands facility. Using notions of practice derived from phenomenology and Bourdieusian sociology and notions of emotional labour we identify two contrasting interpretive repertoires in discussions of compassion. The first, the practical compassion repertoire, evokes the practical, physical and bodily aspects of compassion. It involves organising being with patients, playing games, anticipating disruption and taking them outside for cigarettes. Practitioners described being aware that these practical, bodily activities could lead to patients 'opening up', disclosing their interior concerns and enabling practical, compassionate mental health work to take place. In contrast, the second, organisational repertoire, concerns organisational constraints on compassionate practice. The shortage of staff, the record-keeping and internal processes of quality control were seen as time-greedy and apt to detract from contact with patients. The findings are discussed in relation to Bourdieu and Merleau-Ponty's phenomenological accounts of practice and habit and set in context in the growing interest in placing compassion centrally in healthcare. We also explore how the exercise of compassion in the way our participants describe it can afford the more effective exercise of medical power.

LOD 1 VS. LOD 2 – PRELIMINARY INVESTIGATIONS INTO DIFFERENCES IN MOBILE RENDERING PERFORMANCE

Abstract. The increasing availability, size and detail of 3D City Model datasets has led to a challenge when rendering such data on mobile devices. Understanding the limitations to the usability of such models on these devices is particularly important given the broadening range of applications – such as pollution or noise modelling, tourism, planning, solar potential – for which these datasets and resulting visualisations can be utilized. Much 3D City Model data is created by extrusion of 2D topographic datasets, resulting in what is known as Level of Detail (LoD) 1 buildings – with flat roofs. However, in the UK the National Mapping Agency (the Ordnance Survey, OS) is now releasing test datasets to Level of Detail (LoD) 2 – i.e. including roof structures. These datasets are designed to integrate with the LoD 1 datasets provided by the OS, and provide additional detail in particular on larger buildings and in town centres. The availability of such integrated datasets at two different Levels of Detail permits investigation into the impact of the additional roof structures (and hence the display of a more realistic 3D City Model) on rendering performance on a mobile device. This paper describes preliminary work carried out to investigate this issue, for the test area of the city of Sheffield (in the UK Midlands). The data is stored in a 3D spatial database as triangles and then extracted and served as a web-based data stream which is queried by an App developed on the mobile device (using the Android environment, Java and OpenGL for graphics). Initial tests have been carried out on two dataset sizes, for the city centre and a larger area, rendering the data onto a tablet to compare results. Results of 52 seconds for rendering LoD 1 data, and 72 seconds for LoD 1 mixed with LoD 2 data, show that the impact of LoD 2 is significant.

Performance of hospital spaces in summer: A case study of a ‘Nucleus’-type hospital in the UK Midlands

Nucleus-type Hospital in Glenfield comprises connected cruciform blocks with numerous small courtyards between. The hospital has mechanical ventilation and perimeter heating. The wards have a hybrid ventilation strategy with a low rate of mechanical ventilation. Ventilation through windows is the main source of summer time cooling. This paper investigates the summer time performance of spaces that are mechanically ventilated but passively cooled. The paper presents the measured indoor temperatures in selected hospital spaces and compares them with thermal comfort criteria. Finally, future summer conditions for the ward space are predicted using a calibrated multi zone dynamic thermal model.During June to September 2010, the maximum indoor temperatures in the case study spaces varied between 27.3°C and 29.3°C. The nurse station was found to be the hottest area. During this period the performance of most of the monitored spaces was reasonably within the thermal comfort threshold as defined by HTM03-01. The simulation results demonstrate that light-touch low carbon interventions could produce comfortable conditions in bedrooms into the 2050s in UK Midlands.

Whole-genome sequencing to delineate Mycobacterium tuberculosis outbreaks: a retrospective observational study

SummaryBackgroundTuberculosis incidence in the UK has risen in the past decade. Disease control depends on epidemiological data, which can be difficult to obtain. Whole-genome sequencing can detect microevolution within Mycobacterium tuberculosis strains. We aimed to estimate the genetic diversity of related M tuberculosis strains in the UK Midlands and to investigate how this measurement might be used to investigate community outbreaks.MethodsIn a retrospective observational study, we used Illumina technology to sequence M tuberculosis genomes from an archive of frozen cultures. We characterised isolates into four groups: cross-sectional, longitudinal, household, and community. We measured pairwise nucleotide differences within hosts and between hosts in household outbreaks and estimated the rate of change in DNA sequences. We used the findings to interpret network diagrams constructed from 11 community clusters derived from mycobacterial interspersed repetitive-unit–variable-number tandem-repeat data.FindingsWe sequenced 390 separate isolates from 254 patients, including representatives from all five major lineages of M tuberculosis. The estimated rate of change in DNA sequences was 0·5 single nucleotide polymorphisms (SNPs) per genome per year (95% CI 0·3–0·7) in longitudinal isolates from 30 individuals and 25 families. Divergence is rarely higher than five SNPs in 3 years. 109 (96%) of 114 paired isolates from individuals and households differed by five or fewer SNPs. More than five SNPs separated isolates from none of 69 epidemiologically linked patients, two (15%) of 13 possibly linked patients, and 13 (17%) of 75 epidemiologically unlinked patients (three-way comparison exact p<0·0001). Genetic trees and clinical and epidemiological data suggest that super-spreaders were present in two community clusters.InterpretationWhole-genome sequencing can delineate outbreaks of tuberculosis and allows inference about direction of transmission between cases. The technique could identify super-spreaders and predict the existence of undiagnosed cases, potentially leading to early treatment of infectious patients and their contacts.FundingMedical Research Council, Wellcome Trust, National Institute for Health Research, and the Health Protection Agency.

A whole-genome sequencing approach to targeting Mycobacterium tuberculosis outbreak management

BackgroundEpidemiological investigations into Mycobacterium tuberculosis outbreaks use 24-locus genotyping (MIRU-VNTR typing). Where no epidemiological link can be found between patients, the importance of shared genotypes remains unclear. This issue is especially problematic and time-consuming when tracing contacts within some social groups at high tuberculosis risk, in which unwillingness to volunteer information is common. We investigated whether whole-genome sequencing (WGS) could delineate outbreaks with greater resolution than MIRU-VNTR typing has done. MethodsWe sequenced 390 M tuberculosis isolates from 254 patients from the UK Midlands (1994–2011) using Illumina technology (appendix). We estimated the expected genomic diversity between isolates within a transmission chain by measuring pairwise nucleotide differences between genomes within hosts (79 individuals with pulmonary and extrapulmonary disease, or multiple pulmonary episodes) and between hosts within 25 household outbreaks (63 individuals). We then investigated 11 MIRU-VNTR-based community clusters (168 patients, 157 transmission events) to assess whether WGS could delineate outbreaks more effectively. For each cluster we reconstructed the most plausible transmission chain based on epidemiological data collected by tuberculosis nurses, pairwise nucleotide distances, and times of diagnosis, and compared the genomic diversity across these constructed links with that within individuals and within household outbreaks. Findings109 (96%) of 114 isolates were within five SNPs of another isolate taken from the same individual or from an individual in the same household outbreak. On the basis of longitudinal isolates from individuals or households, we estimated an evolutionary rate of 0·5 SNPs per genome per year, consistent with a maximum of five SNPs between related isolates 3 years or less apart. Using a greater than five SNP threshold to assess 11 MIRU-VNTR-based community clusters, we found that none of 69 epidemiologically related pairs of MIRU-VNTR-matched cases plausibly related by transmission, two of 13 possibly related pairs, and 13 of 75 pairs with no known epidemiological relation were separated by more than five SNPs (p<0·0001). Seven MIRU-VNTR-matched pairs with no epidemiological relation had more than 30 SNPs, five of seven belonging to the same immigrant community cluster. WGS also showed that 62 of 75 MIRU-VNTR-matched pairs for which no epidemiological relation had been identified from contact tracing were highly likely to indicate transmission: in one substance misuse cluster, 38 individuals were linked by five or fewer SNPs without a single epidemiological link having been established previously. Further analysis suggested that microevolutionary divergence of lineages within outbreaks could signal possible super-spreaders, corroborated by clinical and epidemiological data in two clusters. InterpretationWGS can delineate tuberculosis outbreaks with greater resolution than has previously been possible. These findings offer public health teams the potential to limit outbreak investigations to patients who are likely to be linked by recent transmission, irrespective of whether it has been possible to identify epidemiological links, and to save resources where they are not, even in the context of matched MIRU-VNTR genotypes. Uniquely, WGS also provides information about the genetic structure of outbreak clusters, thereby providing the potential to direct public health resources towards individuals most likely to have infected the largest number of secondary cases. As a consequence, the Health Protection Agency is considering introduction of WGS technology for routine tuberculosis public health practice in England. FundingNIHR Oxford Biomedical Research Centre and the UKCRC Modernising Medical Microbiology Consortium (UKCRC Translational Infection Research Initiative supported by MRC, Biotechnology and Biological Sciences Research Council, and NIHR on behalf of the Department of Health [grant G0800778] and the Wellcome Trust [087646/Z/08/Z]).

The great boundary crossing: Perceptions on training pharmacists as supplementary prescribers in the UK

Objective: To explore the perceptions of General Medical Practitioners and pharmacist supplementary prescribers of the training provided for qualification as a pharmacist supplementary prescriber, and the experience of pharmacist supplementary prescribers of subsequent continuing professional development in practice. Design: A qualitative study of pharmacists from the first wave of those trained to become pharmacist supplementary prescribers, comprising interviews, focus groups and documentary analysis of recorded critical incidents. Setting: The research was conducted in three general practices located in two primary care trusts in the UK Midlands. Each practice had a pharmacist supplementary prescriber. Eight pharmacist supplementary prescribers participated, seven of whom were prescribing, all in a general practice setting. Method: A practice-specific focus group was held in each of the three general practices. Two focus groups were held for pharmacists and seven pharmacists were interviewed, six of whom provided two or more critical incidents. Results: Pharmacists were critical of some aspects of the academic training but were unanimous in acknowledging the value of the period of learning in practice and the input of their Designated Medical Practitioner. Learning was recognized by both parties as being reciprocal. Pharmacists’ accounts illustrated a variety of ways in which they undertook continuing professional development, with learning on the job a key component. There was little consensus between General Practitioner partners in two of the practices on the appropriateness of pharmacist supplementary prescribing, discussion focusing on the acquisition of clinical skills. Some partners, particularly those who were Designated Medical Practitioners, saw potential benefits. Conclusion: The coaching relationship between General Practitioner Designated Medical Practitioners and pharmacists served to embed skills and enhance confidence.The reflection skills gained by the pharmacist supplementary prescribers during their academic learning period appear to be important in their subsequent work-based learning.