Search results
Found 23087 matches for
©
NIHR
What is the role of local enhanced services in building clinical research facilities in primary care?
The implementation of a revised government strategy for UK health research led to a reorientation of primary care research, largely focused on recruitment to, and involvement in, clinical trials. This reorientation prompted consideration of new approaches to developing clinical research facilities able to deliver this agenda. The provision of local enhanced services (LES) allow primary care organizations to provide additional services and thereby offer potential for involving primary care staff in clinical research. This paper describes the development and evaluation of one such LES scheme in the East of England, and highlights potential barriers and facilitators to progress. © 2009, Cambridge University Press. All rights reserved.
Best research - For what? Best health - For whom? A critical exploration of primary care research using discourse analysis
Health research is fundamental to the development of improved health and healthcare. Despite its importance, and the role of policy in guiding the kind of research that gets addressed, there are very few empirical studies of health research policy. This paper redresses this, exploring the means by which one area of health research policy is shaped, enabled and constrained. We ask: what are the historical, social and political origins of research policy in primary care in England? What are the key discourses that have dominated debate; and what are the tensions between discourses and the implications this raises for practitioners and policymakers? To answer these questions we employed a Foucauldian approach to discourse analysis to explicitly recognise the historical, social and ideological origins of policy texts; and the role of power and knowledge in policy development. We adapted Parker's framework for distinguishing discourses as a means of selecting and analysing 29 key policy documents; 16 narrative interviews with historical and contemporary policy stakeholders; and additional contextual documents. Our analysis involved detailed deconstruction and linking across texts to reveal prevailing storylines, ideologies, power relations, and tensions. Findings show how powerful policy discourses shaped by historical and social forces influence the type of research undertaken, by whom and how. For instance, recent policy has been shaped by discourse associated with the knowledge-based economy that emphasises microscopic 'discovery', exploitation of information and the contribution of highly technological activities to 'UK plc' and has re-positioned primary care research as a strategic resource and 'population laboratory' for clinical research. Such insights challenge apolitical accounts of health research and reveal how health research serves particular interests. © 2008 Elsevier Ltd. All rights reserved.
Driving out Alternative Ways of Seeing: The Significance of Neo-Liberal Policy Mechanisms for UK Primary Care Research
Health research involves more than the simple generation and use of knowledge and should be considered as a political exercise laden with power relations and strategies for gain. Health research and related policy are pushed and pulled in different directions according to the priorities identified by particular institutions and individuals. I explore the means by which one such area - primary care research - is governed and regulated, by whom, for what potential gain, and to what ends. I employ discourse analysis as a means of appreciating the social and historical contingency of research and the power relations inherent within it and import the theoretical concept of 'governmentality' to situate analysis within the context of neo-liberal politics (a distinct government rationality associated with free-market ideology allowing political objectives to be achieved through 'action at a distance'). Findings show how the relationship between science and government has promoted managerial approaches to the organization and conduct of primary care research manifest in a number of policy mechanisms. These aid standardization of activities and encourage researchers and the organizations in which they are based to take on particular types of research production and practices to the exclusion of others.
Barriers and opportunities for developing sustainable relationships for health improvement: The case of public health and primary care in the UK
The British National Health Service has enjoined public health and primary care via a series of policy initiatives. Inter-organizational relationships provide the foundation for managing the system changes required to deliver policy, but are often taken for granted. This article reports on a study that sought to answer three key questions. First, which relationships are important for improving health? Second, what are the key areas in these relationships that might impact on delivery of improved public health? Third, what issues should be addressed in developing emerging relationships? Following a questionnaire to a sample of primary care organizations and a series of intensive workshops with key informants, findings indicate that there is an extensive network of relationships in which public health staff may participate. However, active participation is problematic in terms of identifying the most relevant relationships and ensuring protected time to develop these. Key relationship dimensions impacting on improved public health included different organizational perceptions of relationships and limited mutual understanding. However, despite a lack of a shared view of public health, the diversity of skills and backgrounds was viewed as an asset to joint working. Emerging relationships were generally perceived to be quite effective and expected to significantly improve though capacity issues and the frequency of organizational change appeared to make relationships more difficult to sustain. These issues needed to be recognized in developing and implementing policy, with further clarity needed as to which relationships are key for public health development and the costs and dividends of supporting these. © 2006 Taylor & Francis.
Research governance: Ethical issues
Healthcare research is haunted by a history of unethical studies in which profound harm was caused to vulnerable individuals. Official systems for gaining ethical approval for research, designed to prevent a repetition of these shameful examples, can prove bureaucratic and inflexible in practice. The core ethical principles of respect for autonomy, prevention of harm, promotion of benefit, and justice (which form the basis of professional codes of research conduct) must be applied flexibly to take account of contextual, methodological, personal and practical considerations. Ensuring that the design and conduct of all research is ethically sound is the responsibility of all involved-including researchers, research institutions, ethics review committees and regulatory bodies.
Research governance: Regulating risk and reducing harm?
Risk assessment can be thought of as the lens through which we anticipate the consequences of research and the impact of the actions of researchers. The way in which risk of harm is managed in research is strongly influenced by the surrounding social and political environment, leading to differences in national and local styles of regulation and review. Different research studies carry different risks, so systems for review and approval must adapt to the question being asked and the nature of the study. Researchers can never wholly guarantee safety in any research but participants and researchers must be offered reasonable protection within any study, with appropriate arrangements in place should something go wrong.
What's in a care pathway? Towards a cultural cartography of the new NHS
Maps are increasingly understood as socio-cultural and political constructs, rather than mirrors of nature. Drawing on the insights of cultural cartographers, this paper presents a critical analysis of a specific instance of map-making in health policy, namely the growing use of care pathways in care planning and service delivery. Widely regarded to date as devices for ensuring quality of care, equity of treatment, optimal resource allocation and a rational division of labour between healthcare professionals, they have been seen as helpful - and technically neutral - tools for routing patients through the system. By contrast, we argue that the metaphors are misleading: lived experience and its objectification in pathway maps continually re-create one another, as we explore the slippage between map, map-making and mapping. This paper is based on interviews and observations with a variety of healthcare workers in three areas of south eastern England. We trace the development of a series of pathways-in-process, and show how they configure the patient, highlighting some aspects of their experiences, whilst silencing others. We also analyse the role of pathways in the carving up and surveillance of space round the emergence of the 'hybrid professional', particularly new practitioners such as GP specialists, specialist nurses, extended scope therapists and others. In considering the wider implications of care pathways as part of the contemporary discourse on policy, the paper critiques the rationalist, and sometimes evangelical assumptions underpinning their current popularity. In particular, we suggest that a critical and processual understanding of pathways might contribute to a more informed appreciation of their potential (and their limitations) as mechanisms for healthcare policy implementation. © Blackwell Publishing Ltd/Foundation for the Sociology of Health & Illness 2005. Published by Blackwell Publishing.
The geographical distribution of specialists in public health in the United Kingdom: Is capacity related to need?
Objectives. Recent organizational changes reflect the need to be more responsive to local populations and have included fostering a closer structural relationship between primary care and public health. In light of this, we explore the distribution of the specialist public health workforce and the relationship with population deprivation and need. Study design. Questionnaire survey to all directors of public health working in primary care trusts (PCTs) and strategic health authorities (SHAs) in England to determine the number of specialists in public health working in either PCTs or SHAs. All identified specialists were given the opportunity to self-define in a further questionnaire survey. Whole-time-equivalent staffing, per head of population, was analysed against socio-economic deprivation, measured by the DETR 2000 Index of Multiple Deprivation. The analysis was conducted at the SHA level. Results. The survey was undertaken whilst public health in the UK was undergoing immense change. This presented specific challenges in identifying specialists in public health working within PCTs and SHAs. Seven hundred and eighty-three specialists working in PCTs and SHAs were identified. On average, in England, there are 1.69 specialists in public health per 100,000 population, with some variability at SHA level (range=0.8-2.89). Findings indicate an overall positive association between capacity at SHA level and socio-economic need, although some discrepancies between need and provision are apparent. Conclusions. The general positive association between capacity and deprivation should offer some reassurance to policy makers, researchers and patients alike. However, further efforts are needed to redistribute specialists in some areas to address organizational capacity and equity issues. © 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
General practices as emergent research organizations: A qualitative study into organizational development
Background. An increasing proportion of research in primary care is locally undertaken in designated research practices. Capacity building to support high quality research at these grass roots is urgently needed and is a government priority. There is little previously published research on the process by which GP practices develop as research organizations or on their specific support needs at organizational level. Methods. Using in-depth qualitative interviews with 28 key informants in 11 research practices across the UK, we explored their historical accounts of the development of research activity. We analysed the data with reference to contemporary theories of organizational development. Results. Participants identified a number of key events and processes, which allowed us to produce a five-phase model of practice development in relation to research activity (creative energy, concrete planning, transformation/differentiation, consolidation and collaboration). Movement between these phases was not linear or continuous, but showed emergent and adaptive properties in which specific triggers and set-backs were often critical. Conclusion. This developmental model challenges previous categorical taxonomies of research practices. It forms a theory-driven framework for providing appropriate support at the grass roots of primary care research, based on the practice's phase of development and the nature of external triggers and potential setbacks. Our findings have important implications for the strategic development of practice-based research in the UK, and could serve as a model for the wider international community. © The Author (2005). Published by Oxford University Press. All rights reserved.
Flattening the national health service hierarchy: The case of public health
Recent re-structurings of the National Health Service (NHS) in England have illustrated the British government's commitment to a policy of devolving resources and responsibilities to local levels. As a result, public health teams are now located in 303 primary care trusts, and are more numerous, and much smaller, than previously. These changes have coincided with a number of other changes within public health (the introduction of an accreditation process for non-medical specialists, and the reorganisation of health protection). The re-organisation has exacerbated existing anxieties about the capacity of the public health workforce. Two recent studies found public health practitioners to be very concerned about the fragmentation of their profession and the resulting isolation in which individuals would work. Directors of Public Health feared that their primary care trust responsibilities would limit the time for their public health work. Multiple local organisations are not well-placed to try to address strategically the long-term problem of an inadequate national public health work force. It was recognised that bringing resources nearer to local communities and the rest of the NHS offered great opportunities for public health to be more responsive to local needs and to harness local resources. Nevertheless, it appears that, not for the first time, the re-organisations of the NHS have not been designed with public health in mind, and it is not yet clear how the challenges of inadequate capacity will be met. © 2005 Taylor & Francis Group Ltd.
Research governance: Where did it come from, what does it mean?
For a variety of historical and social reasons, research has become increasingly formalized and regulated. This change has potential benefits (reduction in fraud and misconduct, protection of vulnerable groups, financial probity) but also disadvantages (increased paperwork, time delays, constraints on research freedom). The terms 'research' and 'governance' mean different things in different contexts. Even with explicit guidance, ambiguities must be resolved by human judgement. Variation in the nature and outcome of approval decisions is therefore a fact of life. The type of approval needed for a research study depends on the official remit of the approval body, the question to be addressed; the methods to be used; the context in which the work will take place; the level of analysis and interpretation; and the plans for how the findings will be presented and used.
Specialist public health capacity in England: Working in the new primary care organizations
Objectives. To determine the capacity and development needs, in relation to key areas of competency and skills, of the specialist public health workforce based in primary care organizations following the 2001 restructuring of the UK National Health Service. Study design. Question naire survey to all consultants and specialists in public health (including directors of public health) based in primary care trusts (PCTs) and strategic health authorities (SHAs) in England. Results. Participants reported a high degree of competency. However, skill gaps were evident in some areas of public health practice, most notably 'developing quality and risk management' and in relation to media communication, computing, management and leadership. In general, medically qualified individuals were weaker on community development than non-medically qualified specialists, and non-medically qualified specialists were less able to perform tasks that require epidemiological or clinical expertise than medically qualified specialists. Less than 50% of specialists felt that their links to external organizations, including public health networks, were strong. Twenty-nine percent of respondents felt professionally isolated and 22% reported inadequate team working within their PCT or SHA. Approximately 21% of respondents expressed concerns that they did not have access to enough expertise to fulfil their tasks and that their skills were not being adequately utilized. Conclusions. Some important skill gaps are evident among the specialist public health workforce although, in general, a high degree of competency was reported. This suggests that the capacity deficit is a problem of numbers of specialists rather than an overall lack of appropriate skills. Professional isolation must be addressed by encouraging greater partnership working across teams. © 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Developing primary care research teams: A qualitative interview study in UK general practice
Few studies have explored the development of practices as research organisations. This paper reports the findings of a study exploring the development of UK research practices and the impact of practice roles on research. Twenty-eight qualitative interviews were undertaken with research team members in a maximum variety sample of 11 research practices. All interviews were tape-recorded, transcribed and analysed using an adaptation of Framework, a systematic method for qualitative data analysis. Research practice development was influenced by motivations to participate in research and by team roles and activity. General practitioners (GPs) regarded their "research role" as one of generating new knowledge, whereas nurses were motivated by the potential for improving care for their specific patient populations. "Research hierarchies" were revealed in practices hosting research, with GPs often leading decision-making and nurses undertaking much of the groundwork. Lack of coordination across research team/s appeared to hinder development, with shared decision-making helping to foster activity. Tensions were evident in managing the interface between research and other practice roles. Findings raise important issues in relation to assumed practice roles. Role issues must be fully addressed in order for research capacity building to be effective, particularly where the role of nursing is being extended.
Comparative analysis of health policy implementation - The use of documentary analysis
Documentary analysis has been widely used in the comparative analysis of health care policy implementation in England. However, the value of the method is rarely debated, and the process whereby it is carried out rarely described in detail, or justified. Documentary analysis has obvious appeal. Documents may be the only source of data at an early stage of a policy innovation. They also present none of the problems (practical, ethical, interactive) of human subjects of research, and can provide a useful supplement to data collected from human subjects by other means. However, official documents are likely to be partial or superficial, representing aspirations rather than realities. The scope for analysis is therefore limited. Analysis may also tend to be positivist in philosophy, taking at face value the 'apparent' meanings of texts. It will be argued in this article, however, that a more interpretative analysis is also possible, when implied assumptions or underlying ideologies are identified and discussed. Thus, in the case of policy documents in the NHS, analysis may focus on one or more of three layers of meanings: those which are overt and explicit in the document; those which reflect the rhetoric of the policy environment and the government's intentions; and, those which reflect the ideology, usually implicit, underpinning policies at local and/or national level.
Evaluation of an interactive educational tool for primary care researchers
This paper describes an evaluation of a computer-assisted learning (CAL) resource for primary care researchers. A two-phase approach was adopted involving a questionnaire survey and follow-up telephone interviews with a purposive sample of respondents. Results indicate wide support for this approach to self-directed learning, particularly for those with less experience. Respondents emphasized the flexibility and accessibility of the resource, with Internet links encouraging users to branch out. Potential barriers included securing protected learning time and lack of interaction with peers.
Public health networks: Mutual aid or another management layer?
The government has introduced the idea of public health networks as a way of addressing the problem of limited public health resources in Primary Care Trusts (PCTs). A number of different concepts of such networks have been proposed, which diverge considerably in the degree to which networks are or are not formally organised and managed. This paper presents data from interviews with PCT Directors of Public Health and representatives of national organisations concerned with the public health/primary care interface. The views expressed were similarly diverse. Some doubted whether networks were necessarily the best way for PCTs to work together, and there were concerns that territoriality right impede joint agendas. The efforts required to establish networks may be significant and expensive.
Public health capacity in the new primary care organizations: Defining a workforce that is fit for the purpose
Recent UK government policy calls for a strong public health function within health and local authority services. The recent restructuring of the National Health Service has drastically changed the organizational structure of Public Health, and has resulted in concerns over the capacity and capabilities of the specialist public health workforce. This paper presents findings from the first phase of a study assessing the capacity and development needs of specialists in public health. Face-to-face semi-structured interviews were conducted with a purposive sample of key public health informants. Four key themes were identified. First, interviewees noted the lack of clarity encompassing the term 'specialist in public health' and the consequent confusion regarding the role of a specialist and the public health function. Second, concern was expressed over the recent fragmentation of the workforce, the loss of critical mass and the potential for professional isolation. This was seen as particularly worrisome in light of a growing public heath agenda. Third, respondents identified key skills gaps within the workforce such as health protection, partnership working and leadership. Last, inadequacies and regional inequities in training and continuing professional development were identified, with interviewees calling for these issues to be addressed immediately. Capacity and skills gaps in the specialist public health workforce are evident and exacerbated by the confusion surrounding the definition of a specialist and, hence, individual roles and responsibilities. The ability of the public health workforce to meet the growing public heath agenda will be dependent on the success of various new mechanisms for joint working, capacity building, and skill enhancement. © 2004 Taylor & Francis Ltd.