Carotid endarterectomy in the U.K. and Ireland: Audit of 30-day outcome

Objectives and Design:A prospective study of 709 patients undergoing carotid surgery in the U.K. and Ireland was performed to evaluate the performance of vascular surgeons.Materials and Methods:Fifty-nine surgeons (range 2–39 cases each) were sampled and all patients undergoing surgery over a 6-month period (1 March 1994–31 August 1994) were included in the study. Indications for surgery were TIA (35.9%), AF (23.3%), CVA (21.4%) and “others” (19.6%).Results:Mean ipsilateral stenosis was 82% (30%–99%). Thirty-one percent of patients had preoperative neurological consults. Shunts were used in 67.6%, tacking sutures in 40.1%, drains in 71.9% and patches in 54.4% of cases. At 30 days there were nine (1.3%) deaths (four cardiac, three neurological). There were 15 ipsilateral postoperative CVAs (2.1%); 19% of patients had one or more complication, usually minor. Statistical analysis showed no independent risk factor for CVA other than seniority of the surgeon.Conclusions:A combined stroke/death rate of 3% for the series was obtained at 30 days for all cases. This large, validated study suggests that members of the Vascular Society of G.B. and Ireland currently have a very low morbidity/mortality rate for performing carotid surgery. Continued audit is required to ensure that this quality of service does not deteriorate

Community-based post-stroke service provision and challenges: a national survey of managers and inter-disciplinary healthcare staff in Ireland.

ABSTRACT: BACKGROUND: The extent of stroke-related disability typically becomes most apparent after patient discharge to the community. Maximising rehabilitation input at this point can minimise the impact of disability. As part of the Irish National Audit of Stroke Care (INASC), a national survey of community-based allied health professionals and public health nurses was conducted. The aim was to document the challenges to service availability for patients with stroke in the community and to identify priorities for service improvement. METHODS: The study was a cross-sectional tailored interview survey with key managerial and service delivery staff. As comprehensive listings of community-based health professionals involved in stroke care were not available, a cascade approach to information gathering was adopted. Representative regional managers for services incorporating stroke care (N=7) and disciplinary allied health professional and public health nurse managers (N=25) were interviewed (94% response rate). RESULTS: Results indicated a lack of formal, structured community-based services for stroke, with no designated clinical posts for stroke care across disciplines nationally. There was significant regional variation in availability of allied health professionals. Considerable inequity was identified in patient access to stroke services, with greater access, where available, for older patients (\u3e65 years). The absence of a stroke strategy and stroke prevalence statistics were identified as significant impediments to service planning, alongside organisational barriers limiting the recruitment of additional allied health professional staff, and lack of sharing of discipline-specific information on patients. CONCLUSIONS: This study highlighted major gaps in the provision of inter-disciplinary team community-based services for people with stroke in one country. Where services existed, they were generic in nature, rarely inter-disciplinary in function and deficient in input from salient disciplines. Challenges to optimal care included the need for strategic planning; increased funding of healthcare staff; increased team resources and teamwork; and removal of service provision barriers based on age. There were notably many challenges beyond funding. Similar evaluations in other healthcare systems would serve to provide comparative lessons to serve to tackle this underserved aspect of care for patients with stroke and their families

The UK overseas territories: A decade of progress and prosperity?

This article analyses the relationship between the UK and its Overseas Territories since the publication of the 1999 White Paper Partnership for Progress and Prosperity. The article considers the efforts by the UK government to improve links with the territories via a new partnership based on mutual obligations and responsibilities. It focuses on the two most important aspects of the White Paper - governance and economic growth and sustainability. Much has been achieved, but fundamental structural problems in the relationship remain unattended. The article concludes by recommending how the relationship can be improved over the coming years. © 2011 Taylor & Francis

Abolishing the Audit Commission:framing, discourse coalitions and administrative reform

The abolition of the Audit Commission in England raises questions about how a major reform was achieved with so little controversy, why the agency lacked the institutional stickiness commonly described in the literature on organisational reform and why it did not strategise to survive. In this paper, we apply argumentative discourse analysis to rich empirical data to reveal the pattern and evolution of storylines and discourse coalitions, and the ways in which these interact with and affect the practices of Parliament, the media and the Audit Commission itself. Our analysis shows that the politics of administrative reform are as much about discursive framing and the ability of pro-reformers to gain discursive structuration and institutionalisation as they are about the material resources available to a newly elected government and its ministers. Questions of technical feasibility are unlikely to derail a reform initiative once its promoters gain discursive ascendency

A qualitative study of primary care clinicians' views of treating childhood obesity

Background: The prevalence of childhood obesity is rising and the UK Government have stated a commitment to addressing obesity in general. One method has been to include indicators relating to obesity within the GP pay-for-performance Quality and Outcomes Framework (QOF) contract. This study aimed to explore general practitioners' and practice nurses' views in relation to their role in treating childhood obesity. Methods: We interviewed eighteen practitioners (twelve GPs and six nurses) who worked in general practices contracting with Rotherham Primary Care Trust. Interviews were face to face and semi structured. The transcribed data were analysed using framework analysis. Results: GPs and practice nurses felt that their role was to raise the issue of a child's weight, but that ultimately obesity was a social and family problem. Time constraint, lack of training and lack of resources were identified as important barriers to addressing childhood obesity. There was concern that the clinician-patient relationship could be adversely affected by discussing what was often seen as a sensitive topic. GPs and practice nurses felt ill-equipped to tackle childhood obesity given the lack of evidence for effective interventions, and were sceptical that providing diet and exercise advice would have any impact upon a child's weight. Conclusion: GPs and practice nurses felt that their role in obesity management was centred upon raising the issue of a child's weight, and providing basic diet and exercise advice. Clinicians may find it difficult to make a significant impact on childhood obesity while the evidence base for effective management remains poor. Until the lack of effective interventions is addressed, implementing additional targets (for example through the QOF) may not be effective

Are physiotherapy students adequately prepared to successfully gain employment?

This is the post-print version of the final paper published in Physiotherapy. The published article is available from the link below. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. Copyright @ 2010 Elsevier B.V.Objectives - To explore the preparedness of final-year physiotherapy students for their progression into employment, and identify what universities can do to facilitate a smooth transition. Design - A single-cohort study, utilising a qualitative design incorporating a survey followed by transcribed and coded semi-structured interviews. Setting - Interviews were held in the Placement and Careers Centre at Brunel University, London. Participants - Sixty final-year full- and part-time students participated in the survey, and 12 final-year full- and part-time students participated in the semi-structured interviews. Methods - Sixty students completed a questionnaire which explored their preparedness for employment. Questions related to the current job situation, the application process and the student's ideal first post. Responses from the questionnaire were analysed and discussed further through a digitally recorded interview. Twelve students were interviewed by an experienced interviewer from a non-physiotherapy background. Results - Students felt unprepared for employment. Forty-seven per cent wanted a rotational post, but 26% would only spend 6 months and 39% would only spend 1 year looking for a job. Seventy-one percent would change career and 99% would work abroad if they were unable to secure a post in the UK. Most importantly, students could not identify transferable skills required by potential employers; only 25% cited effective communications, and 10% cited flexible working as a transferable skill. Self-management skills (e.g. prioritisation, time management and documentation) were not perceived as essential for employment. Conclusions - The job market requires physiotherapy graduates to possess transferable skills which can be applied to any situation. Many are integral to the profession and the undergraduate curriculum; however, analysis and assimilation of these skills cannot be assumed. Universities should reflect on their curriculum delivery to produce graduates who meet employers’ expectations and make a smooth transition into the workplace

The Regeneration Games: Commodities, Gifts and the Economics of London 2012

This paper considers contradictions between two concurrent and tacit conceptions of the Olympic ‘legacy’, setting out one conception that understands the games and their legacies as gifts alongside and as counterpoint to the prevailing discourse, which conceives Olympic assets as commodities. The paper critically examines press and governmental discussion of legacy, in order to locate these in the context of a wider perspective contrasting ‘gift’ and ‘commodity’ Olympics – setting anthropological conceptions of gift-based sociality as a necessary supplement to contractual and dis-embedded socioeconomic organizational assumptions underpinning the commodity Olympics. Costbenefit planning is central to modern city building and mega-event delivery. The paper considers the insufficiency of this approach as the exclusive paradigm within which to frame and manage a dynamic socio-economic and cultural legacy arising from the 2012 games

Assessing relative spending needs of devolved government: the case of healthcare spending in the UK

The system used to allocate resources to the UK's devolved territories, known as the Barnett formula, takes no account of the relative expenditure needs of the territories. In this paper we investigate the prospects of developing a needs based model for allocating healthcare resources to Scotland, Wales and Northern Ireland. We compare the method used by the National Health Service in England to allocate resources geographically within England with the method used by the NHS in Scotland to allocate resources to territorial Health Boards. By applying both approaches to the UK's devolved territories, we are able to examine similarities and differences in the two methods, and explore implications for an assessment of the relative healthcare expenditure need of each territory. The implications for the way in which revenue is distributed to Wales, Scotland and Northern Ireland are discussed

Primary care capitation payments in the UK. An observational study

<p>Abstract</p> <p>Background</p> <p>In 2004 an allocation formula for primary care services was introduced in England and Wales so practices would receive equitable pay. Modifications were made to this formula to enable local health authorities to pay practices.</p> <p>Similar pay formulae were introduced in Scotland and Northern Ireland, but these are unique to the country and therefore could not be included in this study.</p> <p>Objective</p> <p>To examine the extent to which the Global Sum, and modifications to the original formula, determine practice funding.</p> <p>Methods</p> <p>The allocation formula determines basic practice income, the Global Sum. We compared practice Global Sum entitlements using the original and the modified allocation formula calculations.</p> <p>Practices receive an income supplement if Global Sum payments were below historic income in 2004. We examined current overall funding levels to estimate what the effect will be when the income supplements are removed.</p> <p>Results</p> <p>Virtually every Welsh and English practice (97%) received income supplements in 2004. Without the modifications to the formula only 72% of Welsh practices would have needed supplements. No appreciable change would have occurred in England.</p> <p>The formula modifications increased the Global Sum for 99.5% of English practices, while it reduced entitlement for every Welsh practice.</p> <p>In 2008 Welsh practices received approximately £6.15 (9%) less funding per patient per year than an identical English practice. This deficit will increase to 11.2% when the Minimum Practice Income Guarantee is abolished.</p> <p>Conclusions</p> <p>Identical practices in different UK countries do not receive equitable pay. The pay method disadvantages Wales where the population is older and has higher health needs.</p

A qualitative study of diverse providers' behaviour in response to commissioners, patients and innovators in England: research protocol

INTRODUCTION: The variety of organisations providing National Health Service (NHS)-funded services in England is growing. Besides NHS hospitals and general practitioners (GPs), they include corporations, social enterprises, voluntary organisations and others. The degree to which these organisational types vary, however, in the ways they manage and provide services and in the outcomes for service quality, patient experience and innovation, remains unclear. This research will help those who commission NHS services select among the different types of organisation for different tasks. RESEARCH QUESTIONS: The main research questions are how organisationally diverse NHS-funded service providers vary in their responsiveness to patient choice, NHS commissioning and policy changes; and their patterns of innovation. We aim to assess the implications for NHS commissioning and managerial practice which follow from these differences. METHODS AND ANALYSIS: Systematic qualitative comparison across a purposive sample (c.12) of providers selected for maximum variety of organisational type, with qualitative studies of patient experience and choice (in the same sites). We focus is on NHS services heavily used by older people at high risk of hospital admission: community health services; out-of-hours primary care; and secondary care (planned orthopaedics or ophthalmology). The expected outputs will be evidence-based schemas showing how patterns of service development and delivery typically vary between different organisational types of provider. ETHICS, BENEFITS AND DISSEMINATION: We will ensure informants' organisational and individual anonymity when dealing with high profile case studies and a competitive health economy. The frail elderly is a key demographic sector with significant policy and financial implications. For NHS commissioners, patients, doctors and other stakeholders, the main outcome will be better knowledge about the relative merits of different kinds of healthcare provider. Dissemination will make use of strategies suggested by patient and public involvement, as well as DH and service-specific outlets