An examination of the negotiated order of NHS commissioning: a case study of a Clinical Commissioning Group. "Decisions in the absence of objectivity"

Decision-making is a significant part of the business of board level activity in NHS organizations, including the recently created Clinical Commissioning Groups (CCGs). This research explores the behaviour of decision-makers within a CCG as part of a detailed case study focussing on a major strategic decision and looking at the various influences present. The aim being not merely to describe the decision and its outcomes, but to investigate the social interactions of those charged with making the decision and how the influences shape the eventual outcome. The analysis used the concept of the negotiated order, analysing the texts produced in a series of decision-making meetings and qualitative interviews with the decisionmaking participants. Data was analysed through critical discourse analysis within a case study research methodology. Thus, the textual data and generated narratives provided the evidence for how the social relationships and interactions emerged in the case study. The decision-making process demonstrated the negotiated order being created through the power relations of the participants with formed coalitions using and re-shaping cognitive frames. The interpretation of the research findings produced a social power model for organizational decision-making, shaped by the use and exchange of frames within the discourse. This is considered an original contribution to knowledge and supports the further development of the concept of the negotiated order and the use of cognitive frames within organizations. There are a number of implications for management practice that may improve decision-making and help further explorations into upper-echelon behaviour. The research is one of the first to explore the clinically led NHS CCGs and is and a rare example of detailed scrutiny into NHS decisionmaking. Furthermore, the research has a relatively unique position of the researcher as a participant observer already established as a senior position within the organization being studied. This provides a significant contribution to the body of knowledge and research practice of ethnography

Living apart, losing sympathy? How neighbourhood context affects attitudes to redistribution and to welfare recipients

Rising levels of income inequality have been directly linked to rising levels of spatial segregation. In this paper, we explore whether rising segregation may in turn erode support for the redistributive policies of the welfare state, further increasing levels of inequality – a form of positive feedback. The role of the neighbourhood has been neglected in attitudes research but, building on both political geography and ‘neighbourhood effects’ literatures, we theorise that neighbourhood context may shape attitudes through the transmission of attitudes directly and through the accumulation of relevant knowledge. We test this through multilevel modelling of data from England on individual attitudes to redistribution in general and to welfare benefit recipients in particular. We show that the individual factors shaping these attitudes are quite different and that the influence of neighbourhood context also varies as a result. The findings support the idea that neighbourhood context shapes attitudes, with the knowledge accumulation mechanism likely to be the more important. Rising spatial segregation would appear to erode support for redistribution but to increase support for welfare recipients – at least in a context where the dominant media discourse presents such a stigmatising image of those on welfare benefits

Seabird diving behaviour reveals the functional significance of shelf-sea fronts as foraging hotspots

This is the author accepted manuscript. The final version is available from the publisher via the DOI in this record.Oceanic fronts are key habitats for a diverse range of marine predators, yet how they influence fine-scale foraging behaviour is poorly understood. Here, we investigated the dive behaviour of northern gannets Morus bassanus in relation to shelf-sea fronts. We GPS tracked 53 breeding birds and examined the relationship between 1901 foraging dives (from time-depth recorders) and thermal fronts (identified via Earth Observation composite front mapping) in the Celtic Sea, North-East Atlantic. We (1) used a habitat use-availability analysis to determine whether gannets preferentially dived at fronts, and (2) compared dive characteristics in relation to fronts to investigate the functional significance of these oceanographic features. We found that relationships between gannet dive probabilities and fronts varied by frontal metric and sex. Whilst both sexes were more likely to dive in the presence of seasonally persistent fronts, links to more ephemeral features were less clear. Here, males were positively correlated with distance to front and cross-front gradient strength, with the reverse for females. Both sexes performed two dive strategies: shallow V-shaped plunge dives with little or no active swim phase (92% of dives), and deeper U-shaped dives with an active pursuit phase of at least three seconds (8% of dives). When foraging around fronts, gannets were half as likely to engage in U-shaped dives compared with V-shaped dives, independent of sex. Moreover, V-shaped dive durations were significantly shortened around fronts. These behavioural responses support the assertion that fronts are important foraging habitats for marine predators, and suggest a possible mechanistic link between the two in terms of dive behaviour. This research also emphasises the importance of cross-disciplinary research when attempting to understand marine ecosystems.This work was funded by a PhD studentship to SLC by the Natural Environment Research Council (NERC; NE/J500380/1), Natural Resources Wales (Seabirds Cymru) and a NERC grant (NE/H007466/1)

Assessment of the Variability in Influenza A(H1N1) Vaccine Effectiveness Estimates Dependent on Outcome and Methodological Approach

Estimation of Influenza vaccine effectiveness (VE) varies with study design, clinical outcome 10 considered and statistical methodology used. By estimating VE using differing outcomes and 11 statistical methods on the same cohort of individuals the variability in the estimates produced can 12 be better understood. The Pandemic Influenza Primary Care Reporting (PIPeR) cohort of approximately 193,000 individuals 14 was used to estimate pandemic VE in Scotland during season 2009-10. VE results for three 15 outcomes; influenza related consultations, virological confirmed influenza and death were 16 considered. Use of individualised records allowed all models to be adjusted for age, sex, 17 deprivation, risk status relating to chronic illnesses, seasonal vaccination status and a marker of the 18 individual’s propensity to consult. For the consultation and death outcomes, VE was calculated by 19 comparing consultation rates in the unvaccinated and vaccinated groups, adjusted for the listed 20 factors, using both Cox and Poisson regression models. For the consultation outcome, the 21 unvaccinated group was split into individuals before vaccination and those never vaccinated to allow 22 for potential differences in the health seeking behaviour of these groups. For the virology outcome 23 estimates were calculated using a generalised additive logistic regression model. All models were 24 adjusted for time. Vaccine effect was demonstrated for the influenza-like illness consultation outcome using the Cox 26 model (VE=49% 95% CI (19%, 67%)) with lower estimates from the model splitting the before and 27 never vaccinated groups (VE=34.2% with 95% CI (-0.5%, 58.9%)). Vaccine effect was also illustrated 28 for overall mortality (VE=40% (95% CI 18%, 56%)) and a virological confirmed subset of symptomatic 29 individuals (VE=60% (95% CI -38%, 89%))

Temporal patterns in habitat use by small cetaceans at an oceanographically dynamic marine renewable energy test site in the Celtic Sea

Shelf-seas are highly dynamic and oceanographically complex environments, which likely influences the spatio-temporal distributions of marine megafauna such as marine mammals. As such, understanding natural patterns in habitat use by these animals is essential when attempting to ascertain and assess the impacts of anthropogenically induced disturbances, such as those associated with marine renewable energy installations (MREIs). This study uses a five year (2009–2013) passive acoustics (C-POD) dataset to examine the use of an oceanographically dynamic marine renewable energy test site by small cetaceans, dolphins (unspecified delphinids) and harbour porpoises Phocoena phocoena, in the southern Celtic Sea. To examine how temporal patterns in habitat use across the site related to oceanographic changes occurring over broad seasonal scales as well as those driven by fine scale (bi-weekly) localised processes (that may be masked by seasonal trends), separate analyses were conducted using (1) all daily animal detection rates spanning the entire five year dataset and (2) daily animal detection rates taken only during the summer months (defined as mid-June to mid-October) of 2010 (when continuous monitoring was carried out at multiple discrete locations across the site). In both instances, generalised additive mixed effects models (GAMMs) were used to link detection rates to a suite of environmental variables representative of the oceanography of the region. We show that increased harbour porpoise detection rates in the late winter/early spring (January–March) are associated with low sea surface temperatures (SST), whilst peaks in dolphin detection rates in the summer (July–September) coincide with increased SSTs and the presence of a tidal-mixing front. Moreover, across the summer months of 2010, dolphin detection rates were found to respond to small scale changes in SST and position in the spring-neap cycle, possibly reflective of a preference for the stratified waters immediately offshore of the front. Together, these findings suggest that habitat use by small cetaceans within shelf-seas is temporally variable, species specific and likely driven by complex bottom-up processes. As such, the effective conservation management of shelf-seas requires that we understand the dynamic complexities of these systems and the species that inhabit them. In particular, we emphasise the need for a good understanding of the natural drivers of habitat use by marine megafauna before the potential impacts of anthropogenically induced disturbances, such as those associated with the construction, maintenance and operation of MREIs, can be assessed

Issues potentially affecting quality of life arising from long-term medicines use: a qualitative study

Background Polypharmacy is increasing and managing large number of medicines may create a burden for patients. Many patients have negative views of medicines and their use can adversely affect quality of life. No studies have specifically explored the impact of general long-term medicines use on quality of life. Objective To determine the issues which patients taking long-term medicines consider affect their day-to-day lives, including quality of life. Setting Four primary care general practices in North West England Methods Face-to-face interviews with adults living at home, prescribed four or more regular medicines for at least 1 year. Interviewees were identified from primary care medical records and purposively selected to ensure different types of medicines use. Interviews were recorded, transcribed and analysed thematically. Results Twenty-one interviews were conducted and analysed. Patients used an average of 7.8 medicines, 51 % were preventive, 40 % for symptom relief and 9 % treatment. Eight themes emerged: relationships with health professionals, practicalities, information, efficacy, side effects, attitudes, impact and control. Ability to discuss medicines with health professionals varied and many views were coloured by negative experiences, mainly with doctors. All interviewees had developed routines for using multiple medicines, some requiring considerable effort. Few felt able to exert control over medicines routines specified by health professionals. Over half sought additional information about medicines whereas others avoided this, trusting in doctors to guide their medicines use. Patients recognised their inability to assess efficacy for many medicines, notably those used for prophylaxis. All were concerned about possible side effects and some had poor experiences of discussing concerns with doctors. Medicines led to restrictions on social activities and personal life to the extent that, for some, life can revolve around medicines. Conclusion There is a multiplicity and complexity of issues surrounding medicines use, which impact on day-to-day lives for patients with long-term conditions. While most patients adapt to long-term medicines use, others did so at some cost to their quality of life

Dataset of British English speech recordings for psychoacoustics and speech processing research: The clarity speech corpus

This paper presents the Clarity Speech Corpus, a publicly available, forty speaker British English speech dataset. The corpus was created for the purpose of running listening tests to gauge speech intelligibility and quality in the Clarity Project, which has the goal of advancing speech signal processing by hearing aids through a series of challenges. The dataset is suitable for machine learning and other uses in speech and hearing technology, acoustics and psychoacoustics. The data comprises recordings of approximately 10,000 sentences drawn from the British National Corpus (BNC) with suitable length, words and grammatical construction for speech intelligibility testing. The collection process involved the selection of a subset of BNC sentences, the recording of these produced by 40 British English speakers, and the processing of these recordings to create individual sentence recordings with associated transcripts and metadata