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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Health worker experiences of implementing TB infection prevention and control: A qualitative evidence synthesis to inform implementation recommendations
Implementation of TB infection prevention and control (IPC) measures in health facilities is frequently inadequate, despite nosocomial TB transmission to patients and health workers causing harm. We aimed to review qualitative evidence of the complexity associated with implementing TB IPC, to help guide the development of TB IPC implementation plans. We undertook a qualitative evidence synthesis of studies that used qualitative methods to explore the experiences of health workers implementing TB IPC in health facilities. We searched eight databases in November 2021, complemented by citation tracking. Two reviewers screened titles and abstracts and reviewed full texts of potentially eligible papers. We used the Critical Appraisals Skills Programme checklist for quality appraisal, thematic synthesis to identify key findings and the GRADE-CERQual method to appraise the certainty of review findings. The review protocol was pre-registered on PROSPERO, ID CRD42020165314. We screened 1062 titles and abstracts and reviewed 102 full texts, with 37 studies included in the synthesis. We developed 10 key findings, five of which we had high confidence in. We describe several components of TB IPC as a complex intervention. Health workers were influenced by their personal occupational TB risk perceptions when deciding whether to implement TB IPC and neglected the contribution of TB IPC to patient safety. Health workers and researchers expressed multiple uncertainties (for example the duration of infectiousness of people with TB), assumptions and misconceptions about what constitutes effective TB IPC, including focussing TB IPC on patients known with TB on treatment who pose a small risk of transmission. Instead, TB IPC resources should target high risk areas for transmission (crowded, poorly ventilated spaces). Furthermore, TB IPC implementation plans should support health workers to translate TB IPC guidelines to local contexts, including how to navigate unintended stigma caused by IPC, and using limited IPC resources effectively.
Missed SDG targets: from ‘trying harder’ to engaging critically with paradox and conflict
This article explores a radical hypothesis: that our repeated failure to achieve the Sustainable Development Goals (SDGs) signals something inherently paradoxical within the current approach, suggesting that simply doing ‘more of the same’ will not transform the fortunes of the failing SDG mission. We examine four interrelated paradoxes–those of universality, implementation, information, and signification–that characterize the dominant approach to the SDGs. These paradoxes, which apply across all the SDGs, are illustrated through SDG 11 (Sustainable Cities and Communities), which seeks to ‘make cities inclusive, safe, resilient, and sustainable’. We argue for recognizing the political double-voicing embedded in a top-down ‘we’ that imposes obligations on a bottom-up ‘we’ it claims to represent. Furthermore, we contend that implementation plans, rather than being the most efficient route to achieving the SDGs, risk recasting the SDG challenge as a technical issue, overshadowing the political and ethical questions in problem framing. Additionally, we critique the reliance on metrics as straightforward conduits to objective truth, advocating instead for ‘critical datathons’ that question prevailing narratives of truth and progress while exploring alternative perspectives. Finally, we caution against the use of popular terms that have become empty signifiers; having lost their specific meanings, these terms risk confusing, distracting, or even obscuring critical issues. We propose that reframing these paradoxes offers a path toward a deeper understanding of the structural challenges within the SDG mission, suggesting a more reflective and critical approach to sustainable development.
The impact of remote care approaches on continuity in primary care: A mixed-studies systematic review
Background The value of continuity in primary care has been demonstrated for multiple positive outcomes. However, little is known about how the expansion of remote and digital care models in primary care have impacted continuity. Aim To explore the impact of the expansion of remote and digital care models on continuity in primary care. Design and setting A systematic review of continuity in primary care. Method A keyword search of Embase, MEDLINE, and CINAHL databases was used along with snowball sampling to identify relevant English-language qualitative and quantitative studies from any country between 2000 and 2022, which explored remote or digital approaches in primary care and continuity. Relevant data were extracted, analysed using GRADE-CERQual, and narratively synthesised. Results Fifteen studies were included in the review. The specific impact of remote approaches on continuity was rarely overtly addressed. Some patients expressed a preference for relational continuity depending on circumstance, problem, and context; others prioritised access. Clinicians valued continuity, with some viewing remote consultations more suitable where there was high episodic or relational continuity. With lower continuity, patients and clinicians considered remote consultations harder, higher risk, and poorer quality. Some evidence suggested that remote approaches and/or their implementation risked worsening inequalities and causing harm by reducing continuity where it was valuable. However, if deployed strategically and flexibly, remote approaches could improve continuity. Conclusion While the value of continuity in primary care has previously been well demonstrated, the dearth of evidence around continuity in a remote and digital context is troubling. Further research is, therefore, needed to explore the links between the shift to remote care, continuity and equity, using realworld evaluation frameworks to ascertain when and for whom continuity adds most value, and how this can be enabled or maintained.
Protocol: Remote care as the 'new normal'? Multi-site case study in UK general practice.
BackgroundFollowing a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices' varied experiences over time as they seek to establish remote forms of accessing and delivering care.MethodsThis protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups).Results anticipatedWe expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint).ConclusionBy using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.
Remote care in UK general practice: baseline data on 11 case studies.
BackgroundAccessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs.MethodsMixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data.ResultsReflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts.ConclusionsGeneral practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.
Why doesn’t integrated care work? Using Strong Structuration Theory to explain the limitations of an English case
Integrated care is an aim and a method for organising health and care services, particularly for older people and those with chronic conditions. Policy expects that integrated care programmes will provide person-centred coordinated care which will improve patient or client experience, enable population health, prevent hospital admissions and thereby reduce costs. However, empirical evaluations of integrated care interventions have shown disappointing results. We analysed an in-depth case study using Strong Structuration Theory to ask: how and why have efforts to integrate health and social care failed to produce desired outcomes? In our case, integrated case management and the creation of cost-saving plans were dominant practices. People working in health and social care recursively produced a structure of integrated care: a recognised set of resources created by collective activities. Integrated care, intended to help patients manage their long-term conditions and avoid hospital admission, was only a small part of the complex network that sustained patients at home. The structures of integrated care were unable to compensate for changes in patients’ health. The result was that patients’ experiences remained largely unaffected and hospital admissions were not easily avoided.
What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic?
The question of whether SARS-CoV-2 is mainly transmitted by droplets or aerosols has been highly controversial. We sought to explain this controversy through a historical analysis of transmission research in other diseases. For most of human history, the dominant paradigm was that many diseases were carried by the air, often over long distances and in a phantasmagorical way. This miasmatic paradigm was challenged in the mid to late 19th century with the rise of germ theory, and as diseases such as cholera, puerperal fever, and malaria were found to actually transmit in other ways. Motivated by his views on the importance of contact/droplet infection, and the resistance he encountered from the remaining influence of miasma theory, prominent public health official Charles Chapin in 1910 helped initiate a successful paradigm shift, deeming airborne transmission most unlikely. This new paradigm became dominant. However, the lack of understanding of aerosols led to systematic errors in the interpretation of research evidence on transmission pathways. For the next five decades, airborne transmission was considered of negligible or minor importance for all major respiratory diseases, until a demonstration of airborne transmission of tuberculosis (which had been mistakenly thought to be transmitted by droplets) in 1962. The contact/droplet paradigm remained dominant, and only a few diseases were widely accepted as airborne before COVID-19: those that were clearly transmitted to people not in the same room. The acceleration of interdisciplinary research inspired by the COVID-19 pandemic has shown that airborne transmission is a major mode of transmission for this disease, and is likely to be significant for many respiratory infectious diseases.
What does the literature mean by social prescribing? A critical review using discourse analysis
Social prescribing (SP) seeks to enhance the role of the voluntary and community sector in addressing patients' complex needs in primary care. Using discourse analysis, this review investigates how SP is framed in the scientific literature and explores its consequences for service delivery. Theory driven searches identified 89 academic articles and grey literature that included both qualitative and quantitative evidence. Across the literature three main discourses were identified. The first one emphasised increasing social inequalities behind escalating health problems and presented SP as a response to the social determinants of health. The second one problematised people's increasing use of health services and depicted SP as a means of enhancing self-care. The third one stressed the dearth of human and relational dimensions in general practice and claimed that SP could restore personalised care. Discourses circulated unevenly in the scientific literature, conditioned by a wider political rationality which emphasised individual responsibility and framed SP as ‘solution’ to complex and contentious problems. Critically, this contributed to an oversimplification of the realities of the problems being addressed and the delivery of SP. We propose an alternative ‘care-based’ framing of SP which prioritises (and evaluates) holistic, sustained and accessible practices within strengthened primary care systems.
A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age
Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs). Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and ‘tinkering’ by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving—to a greater or lesser extent—continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations. Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity—of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.
Implementation challenges of electronic blood transfusion safety systems: Lessons from an international, multi-site comparative case study
Background: Severe transfusion reactions resulting from errors in matching the correct blood with the correct patient are considered never events. Despite the relative technical simplicity of barcode scanning for patient-blood bag matching, the adoption and universal application of this safety measure are by no means universal. This study highlights the logistical and institutional challenges associated with spreading, scaling up, and sustaining such IT-supported safety measures in healthcare. Study Design and Methods: We report findings from a 5-year, prospective, multi-site case study conducted across one hospital in England and three hospitals in the Netherlands. Ethnographic methods, including interviews and observations, were used at each site to investigate the implementation of barcode scanning-supported safety pathways for blood transfusions. Results: Significant variation was observed across the sites in the adoption and implementation of barcode scanning-supported safety pathways. Despite the potential for reducing transfusion errors, the introduction of this innovation was met with varying levels of success in different settings. Discussion: This study highlights the critical role of inter-hospital learning and flexible system design in successfully implementing barcode scanning-supported safety pathways for blood transfusions. A more structured, national-level network for knowledge sharing could enhance the spread and sustainability of such innovations across healthcare settings.
Airborne infection prevention and control implementation: A positive deviant organisational case study of tuberculosis and COVID-19 at a South African rural district hospital
There are many examples of poor TB infection prevention and control (IPC) implementation in the academic literature, describing a high-risk environment for nosocomial spread of airborne diseases to patients and health workers. We developed a positive deviant organisational case study drawing on Weick’s theory of organisational sensemaking. We focused on a district hospital in the rural Eastern Cape, South Africa and used four primary care clinics as comparator sites. We interviewed 18 health workers to understand TB IPC implementation over time. We included follow-up interviews on interactions between TB and COVID-19 IPC. We found that TB IPC implementation at the district hospital was strengthened by continually adapting strategies based on synergistic interventions (e.g. TB triage and staff health services), changes in what value health workers attached to TB IPC and establishing organisational TB IPC norms. The COVID-19 pandemic severely tested organisational resilience and COVID-19 IPC measures competed instead of acted synergistically with TB. Yet there is the opportunity for applying COVID-19 IPC organisational narratives to TB IPC to support its use. Based on this positive deviant case we recommend viewing TB IPC implementation as a social process where health workers contribute to how evidence is interpreted and applied.