Risk - An Opportunity or Threat for Entrepreneurial Farmers in the Global Food Market?

uncertainty, farm management, opportunities, threats, Agribusiness, Q12,

A balanced approach to identifying, prioritising and evaluating all potential consequences of quality improvement:modified Delphi study

Objectives Healthcare is a complex system, so quality improvement will commonly lead to unintended consequences which are rarely evaluated. In previous qualitative work, we proposed a framework for considering the range of these potential consequences, in terms of their desirability and the extent to which they were predictable or expected during planning. This paper elaborates on the previous findings, using consensus methods to examine what consequences should be identified, why and how to prioritise, evaluate and interpret all identified consequences, and what stakeholders should be involved throughout this process. Design Two-round modified Delphi consensus study. Setting and participants Both rounds were completed by 60 panellists from an academic, clinical or management background and experience in designing, implementing or evaluating quality improvement programmes. Results Panellists agreed that trade-offs (expected undesirable consequences) and unpleasant surprises (unexpected undesirable consequences) should be actively considered. Measurement of harmful consequences for patients, and those with high workload or financial impact was prioritised, and their evaluation could also involve the use of qualitative methods. Clinical teams were agreed as important to involve at all stages, from identifying potential consequences, prioritising which of those to systematically evaluate, undertaking appropriate evaluation and interpreting the findings. Patients were necessary in identifying consequences, managers in identifying and prioritising, and improvement advisors in interpreting the data. Conclusion There was consensus that a balanced approach to considering all the consequences of improvement can be achieved by carefully considering predictable trade-offs from the outset and deliberately pausing after implementation to identify any unexpected surprises and make an informed decision as to whether quantitative or qualitative evaluation is needed and feasible. Stakeholders' roles in in the process of identifying, prioritising, evaluating and interpreting potential consequences should be explicitly addressed within planning and revisited during and after implementation

An integrated model for the nucleo-cytoplasmic transport of cytoplasmic poly(A)-binding proteins

Cytoplasmic poly(A)-binding proteins (PABPs) regulate mRNA stability and translation. Although predominantly localized in the cytoplasm, PABP proteins also cycle through the nucleus. Recent work has established that their steady-state localization can be altered by cellular stresses such as ultraviolet (UV) radiation, and infection by several viruses, resulting in nuclear accumulation of PABPs. Here, we present further evidence that their interaction with and release from mRNA and translation complexes are important in determining their sub-cellular distribution and propose an integrated model for regulated nucleo-cytoplasmic transport of PABPs

Balancing measures or a balanced accounting of improvement impact:a qualitative analysis of individual and focus group interviews with improvement experts in Scotland

Background As quality improvement (QI) programmes have become progressively larger scale, the risks of implementation having unintended consequences are increasingly recognised. More routine use of balancing measures to monitor unintended consequences has been proposed to evaluate overall effectiveness, but in practice published improvement interventions hardly ever report identification or measurement of consequences other than intended goals of improvement. Methods We conducted 15 semistructured interviews and two focus groups with 24 improvement experts to explore the current understanding of balancing measures in QI and inform a more balanced accounting of the overall impact of improvement interventions. Data were analysed iteratively using the framework approach. Results Participants described the consequences of improvement in terms of desirability/undesirability and the extent to which they were expected/unexpected when planning improvement. Four types of consequences were defined: expected desirable consequences (goals); expected undesirable consequences (trade-offs); unexpected undesirable consequences (unpleasant surprises); and unexpected desirable consequences (pleasant surprises). Unexpected consequences were considered important but rarely measured in existing programmes, and an improvement pause to take stock after implementation would allow these to be more actively identified and managed. A balanced accounting of all consequences of improvement interventions can facilitate staff engagement and reduce resistance to change, but has to be offset against the cost of additional data collection. Conclusion Improvement measurement is usually focused on measuring intended goals, with minimal use of balancing measures which when used, typically monitor trade-offs expected before implementation. This paper proposes that improvers and leaders should seek a balanced accounting of all consequences of improvement across the life of an improvement programme, including deliberately pausing after implementation to identify and quantitatively or qualitatively evaluate any pleasant or unpleasant surprises

Emergency supply of prescription-only medicines to patients by community pharmacists: a mixed methods evaluation incorporating patient, pharmacist and GP perspectives

Objective To evaluate and inform emergency supply of prescription-only medicines by community pharmacists (CPs), including how the service could form an integral component of established healthcare provision to maximise adherence. Design Mixed methods. 4 phases: prospective audit of emergency supply requests for prescribed medicines (October–November 2012 and April 2013); interviews with CPs (February–April 2013); follow-up interviews with patients (April–May 2013); interactive feedback sessions with general practice teams (October–November 2013). Setting 22 community pharmacies and 6 general practices in Northwest England. Participants 27 CPs with experience of dealing with requests for emergency supplies; 25 patients who received an emergency supply of a prescribed medicine; 58 staff at 6 general practices. Results Clinical audit in 22 pharmacies over two 4-week periods reported that 526 medicines were requested by 450 patients. Requests peaked over a bank holiday and around weekends. A significant number of supplies were made during practice opening hours. Most requests were for older patients and for medicines used in long-term conditions. Difficulty in renewing repeat medication (forgetting to order, or prescription delays) was the major reason for requests. The majority of medicines were ‘loaned’ in advance of a National Health Service (NHS) prescription. Interviews with CPs and patients indicated that continuous supply had a positive impact on medicines adherence, removing the need to access urgent care. General practice staff were surprised and concerned by the extent of emergency supply episodes. Conclusions CPs regularly provide emergency supplies to patients who run out of their repeat medication, including during practice opening hours. This may aid adherence. There is currently no feedback loop, however, to general practice. Patient care and interprofessional communication may be better served by the introduction of a formally structured and funded NHS emergency supply service from community pharmacies, with ongoing optimisation of repeat prescribing

Perceived impact of formulating, implementing and enacting national mental health policies recommendations in practice:An exploratory qualitative study within child and adolescent mental health services in Scotland

OBJECTIVE: To understand the process of formulating, implementing and enacting national recommendations into practice, by exploring the interactions between government policymakers and national and local organisations supporting and delivering policy implementation within a Child and Adolescent Mental Health Service (CAMHS) context in Scotland. METHODS: Data collection involved 16 semi-structured individual and four focus group interviews with a purposeful sample of policymakers, national health and social care stakeholders and local outpatient and inpatient CAMHS teams representing three NHS health boards in Scotland. RESULTS: Study participants highlighted the challenges of navigating through evolving and often conflicting policy agendas, seen to not acknowledging the current evidence base or experiential learning from services and prior evaluations. Accounts of transformation fatigue often emerged from increased expectations for staff to adopt new approaches to accommodate constantly changing recommendations. Participants also reported a lack of integration and implementation support from national health and social care organisations, leading to duplication of effort and gaps in provision or waste. Policy recommendations were perceived as sometimes vague, lacking clarity about how to deliver service transformation using a whole-system approach. The collective narratives reflected increased tension between the need for local autonomy to innovate and the limitations created vertically by the relative inflexibility of policy recommendations, and horizontally by the proliferation of national organisations delivering the same transformation aims using different approaches in a resource-constrained environment. CONCLUSION: The findings contribute to the wider literature by offering an exploration of importance of evaluation and evidence uptake in policy formulation; the roles and remits in supporting the implementation of policy recommendations; and how the dynamics of central control and local autonomy might impact on the local enactment of policy recommendations

Pharmacist and Data-driven Quality Improvement in Primary Care (P-DQIP):A qualitative study of anticipated implementation factors informed by the Theoretical Domains Framework

Objectives: The quality and safety of drug therapy in primary care are global concerns. The Pharmacist and Data driven Quality Improvement in Primary care (P-DQIP) intervention aims to improve prescribing safety via an informatics tool which facilitates proactive management of drug therapy risks (DTRs) by health-board employed pharmacists with established roles in general practices. Study objectives were (1) to identify and prioritise factors that could influence P-DQIP implementation from the perspective of practice pharmacists, and (2) to identify potentially effective, acceptable and feasible strategies to support P-DQIP implementation. Design: Semi-structured face-to-face interviews using a Theoretical Domains Framework (TDF) informed topic guide. The framework method was used for data analysis. Identified implementation factors were prioritised for intervention based on research team consensus. Candidate intervention functions, behaviour change techniques (BCTs) and policies targeting these were identified from the Behaviour Change Wheel. The final intervention content and modes of delivery were agreed with local senior pharmacists. Setting: General practices from three Health and Social Care Partnerships (HSCPs) in NHS Tayside. Participants: 14 NHS employed practice pharmacists. Results: Identified implementation factors were linked to thirteen theoretical domains (all except intentions) and six (skill, memory/attention/decision-making, behavioural regulation, reinforcement, environmental context/resources, social influences) were prioritised. Three intervention functions (training, enablement, and environmental restructuring) were relevant and were served by two policy categories (guidelines, communication/marketing) and eight BCTs (Instructions on how to perform a behaviour, problem solving, action planning, prompt/cues, goal setting, self-monitoring, feedback, restructuring the social environment). Intervention components encompass an informatics tool, written educational material, a workshop for pharmacists, promotional activities, and small financial incentives. Conclusions: This study explored pharmacists’ perceptions of implementation factors which could influence management of DTRs in general practices to inform implementation of P-DQIP, which will initially be implemented in one Scottish health board with parallel evaluation of effectiveness and implementation