The medium-term sustainability of organisational innovations in the national health service

Background: There is a growing recognition of the importance of introducing new ways of working into the UK's National Health Service (NHS) and other health systems, in order to ensure that patient care is provided as effectively and efficiently as possible. Researchers have examined the challenges of introducing new ways of working-'organisational innovations'-into complex organisations such as the NHS, and this has given rise to a much better understanding of how this takes place-and why seemingly good ideas do not always result in changes in practice. However, there has been less research on the medium-and longer-term outcomes for organisational innovations and on the question of how new ways of working, introduced by frontline clinicians and managers, are sustained and become established in day-to-day practice. Clearly, this question of sustainability is crucial if the gains in patient care that derive from organisational innovations are to be maintained, rather than lost to what the NHS Institute has called the 'improvement-evaporation effect'. Methods: The study will involve research in four case-study sites around England, each of which was successful in sustaining its new model of service provision beyond an initial period of pilot funding for new genetics services provided by the Department of Health. Building on findings relating to the introduction and sustainability of these services already gained from an earlier study, the research will use qualitative methods-in-depth interviews, observation of key meetings, and analysis of relevant documents-to understand the longer-term challenges involved in each case and how these were surmounted. The research will provide lessons for those seeking to sustain their own organisational innovations in wide-ranging clinical areas and for those designing the systems and organisations that make up the NHS, to make them more receptive contexts for the sustainment of innovation. Discussion: Through comparison and contrast across four sites, each involving different organisational innovations, different forms of leadership, and different organisational contexts to contend with, the findings of the study will have wide relevance. The research will produce outputs that are useful for managers and clinicians responsible for organisational innovation, policy makers and senior managers, and academics

The origin of platelets enabled the evolution of eutherian placentation

Invasive placentation with extended pregnancy is a shared derived characteristic unique to eutherian mammals that possess a highly effective system of haemostasis, platelets. These are found in all mammals but no other group of animals. We propose that platelets and megakaryocytes (large polyploid nucleated bone marrow cells that produce platelets) evolved from an ancestral 2 N thrombocyte by polyploidization and that the possession of platelets enabled the evolution of invasive placentation. This could explain why invasive placentation is limited to mammals

Varroa destructor reproduction and cell re-capping in mite-resistant Apis mellifera populations

Globalization has facilitated the spread of emerging pests such as the Varroa destructor mite, resulting in the near global distribution of the pest. In South African and Brazilian honey bees, mite-resistant colonies appeared within a decade; in Europe, mite-resistant colonies are rare, but several of these exhibited high levels of “re-capping” behavior. We studied re-capping in Varroa-naïve (UK/Australia) and Varroa-resistant (South Africa and Brazil) populations and found very low and very high levels, respectively, with the resistant populations targeting mite-infested cells. Furthermore, 54% of artificially infested A. m. capensis worker cells were removed after 10 days and 83% of the remaining infested cells were re-capped. Such targeted re-capping of drone cells did not occur. We propose that cell opening is a fundamental trait in mite-resistant populations and that re-capping is an accurate proxy for this behavior

Bringing genetics into primary care: findings from a national evaluation of pilots in England

Objectives: Developments in genetic knowledge and clinical applications are seen as rendering traditional modes of organizing genetics provision increasingly inappropriate. In common with a number of developed world countries the UK has sought to increase the role of primary care in delivering such services. However, efforts to reconfigure service delivery face multiple challenges associated with divergent policy objectives, organizational boundaries and professional cultures. This paper presents findings from an evaluation of an English initiative to integrate genetics into 'mainstream' clinical provision in the National Health Service. Methods: Qualitative research in 11 case-study sites focusing on attempts by pilots funded by the initiative to embed knowledge and provision within primary care illustrating barriers faced and the ways in which these were surmounted. Results: Lack of intrinsic interest in clinical genetics among primary care staff was compounded by national targets that focused their attention elsewhere and by service structures that rendered genetics a peripheral concern demanding minimal engagement. Established divisions between the commissioning of mainstream and specialist services, along with the pressures of shorter-term targets, impeded ongoing funding. Conclusions: More wide-ranging policy and organizational support is required if the aim of entrenching genetics knowledge and practice across the Health Service is to be realized

Conflicting logics of public relations in the English NHS: a qualitative study of communications and engagement

Since the formation of the NHS, all UK citizens have been entitled to access a universal health service, but radical changes to the NHS are now occurring. Although recent NHS policy claims that ‘the NHS belongs to us all’ and ‘the NHS is a social movement’, these collectivist rhetorical claims appear when such communitarian discourse is under threat, as NHS England’s (2014) Five Year Forward View tries to square the circle of efficiency, quality and equity. Historically, patients and user-groups have formed support networks and social movements, and collectively campaigned for their voices to be heard by policy makers, clinicians and managers. In contrast to the discourse of user movements, the field of marketing and public relations generally relies on the idea of the public as consumers rather than citizens. As complex governance arrangements blur the lines between public and private, concerns have been raised about how ‘spin’ associated with public relations might contravene accountability, communicative rationality and deliberative or participatory democracy. Using qualitative methods, we conducted empirical research in two localities to explore the role of communications and engagement staff as they worked to ‘transform’ the NHS in line with the vision of the Five Year Forward View. We gathered documentary data and interview data from people whose roles required them to ‘do engagement’. These staff came from a range of backgrounds, including professional marketing backgrounds, and many were unaware of emancipatory goals or user-led involvement and activism. Our analysis examines the competing logics of marketing and patient empowerment within a key stakeholder matrix document and that surfaced in participants’ accounts of their engagement practices.NIH

Effect of pulsed methylprednisolone on pain, in patients with HTLV-1-associated myelopathy

HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is an immune mediated myelopathy caused by the human T-lymphotropic virus type 1 (HTLV-1). The efficacy of treatments used for patients with HAM/TSP is uncertain. The aim of this study is to document the efficacy of pulsed methylprednisolone in patients with HAM/TSP. Data from an open cohort of 26 patients with HAM/TSP was retrospectively analysed. 1g IV methylprednisolone was infused on three consecutive days. The outcomes were pain, gait, urinary frequency and nocturia, a range of inflammatory markers and HTLV-1 proviral load. Treatment was well tolerated in all but one patient. Significant improvements in pain were: observed immediately, unrelated to duration of disease and maintained for three months. Improvement in gait was only seen on Day 3 of treatment. Baseline cytokine concentrations did not correlate to baseline pain or gait impairment but a decrease in tumour necrosis factor-alpha (TNF-α) concentration after pulsed methylprednisolone was associated with improvements in both. Until compared with placebo, treatment with pulsed methylprednisolone should be offered to patients with HAM/TSP for the treatment of pain present despite regular analgesia

Science, society, and policy in the face of uncertainty: reflections on the debate around face coverings for the public during COVID-19

The Covid-19 pandemic has had enormous effects on health, wellbeing and economies worldwide. Governments have responded with rapid and sometimes radical public health interventions. As nations grapple with the question of how to regain normality without unnecessarily endangering lives or healthcare systems, some scientists have argued for policies to encourage or compel use of face coverings in community (non-clinical) settings, despite acknowledged gaps in the evidence base for the effectiveness of such a measure. This commentary has two objectives. First, in the face of strong arguments that face coverings are a commonsense intervention, with negligible downsides, that can only do good, we make the case for caution in changing policy. Many seemingly benign public health interventions have the potential to cause harm, and that harm is often socially differentiated. We present five arguments for caution in policy change. Second, we reflect on the wider implications of the increasingly overt approaches to policy advocacy taken by some scientists. Drawing from the theory of post-normal science, we argue that the science-policy interface in the case of face coverings has taken a surprisingly traditional form, falling short of interdisciplinary integration and failing to incorporate insights of the full range of relevant experts and affected stakeholders. We sketch a vision for an alternative, more mature, relationship between science and society that accepts uncertainty, embraces deliberation, and rises to the challenge of developing knowledge to improve public health

Phylogenetic relationships of typical antbirds (Thamnophilidae) and test of incongruence based on Bayes factors

BACKGROUND: The typical antbirds (Thamnophilidae) form a monophyletic and diverse family of suboscine passerines that inhabit neotropical forests. However, the phylogenetic relationships within this assemblage are poorly understood. Herein, we present a hypothesis of the generic relationships of this group based on Bayesian inference analyses of two nuclear introns and the mitochondrial cytochrome b gene. The level of phylogenetic congruence between the individual genes has been investigated utilizing Bayes factors. We also explore how changes in the substitution models affected the observed incongruence between partitions of our data set. RESULTS: The phylogenetic analysis supports both novel relationships, as well as traditional groupings. Among the more interesting novel relationship suggested is that the Terenura antwrens, the wing-banded antbird (Myrmornis torquata), the spot-winged antshrike (Pygiptila stellaris) and the russet antshrike (Thamnistes anabatinus) are sisters to all other typical antbirds. The remaining genera fall into two major clades. The first includes antshrikes, antvireos and the Herpsilochmus antwrens, while the second clade consists of most antwren genera, the Myrmeciza antbirds, the "professional" ant-following antbirds, and allied species. Our results also support previously suggested polyphyly of Myrmotherula antwrens and Myrmeciza antbirds. The tests of phylogenetic incongruence, using Bayes factors, clearly suggests that allowing the gene partitions to have separate topology parameters clearly increased the model likelihood. However, changing a component of the nucleotide substitution model had much higher impact on the model likelihood. CONCLUSIONS: The phylogenetic results are in broad agreement with traditional classification of the typical antbirds, but some relationships are unexpected based on external morphology. In these cases their true affinities may have been obscured by convergent evolution and morphological adaptations to new habitats or food sources, and genera like Myrmeciza antbirds and the Myrmotherula antwrens obviously need taxonomic revisions. Although, Bayes factors seem promising for evaluating the relative contribution of components to an evolutionary model, the results suggests that even if strong evidence for a model allowing separate topology parameters is found, this might not mean strong evidence for separate gene phylogenies, as long as vital components of the substitution model are still missing