Charlotte Humphrey

Hearing impairment and mental state in the elderly living at home.

Altogether 153 (60%) out of a sample of 253 people aged 70 years and over living in their own homes were found to have impaired hearing when tested by pure-tone audiometry. This is almost twice the prevalence found in all other studies, in which deafness was assessed clinically or by self-reporting. The prevalence of deafness increased with age. Evidence of organic brain syndrome (dementia), as determined by questionnaire, was present in 39 (16%) out of 245 respondents, and of depression in 82 (35%). Dementia and depression were both age related. An apparent association between deafness and dementia was shown to be due to age alone. A significant relation between deafness and depression was independent of age and socioeconomic state. The use of audiometric techniques of assessment established that an association exists between deafness and depression that is not simply a function of differential reporting reflecting the emotional state of the respondent.

Some characteristics of the hearing-impaired elderly who do not present themselves for rehabilitation.

Social and audiometric characteristics of the hearing-impaired elderly without aids have been analysed and some understanding developed of the factors which lead people to seek rehabilitation. The two major single determinants of seeking help were found to be severity of impairment and onset of deafness before reaching retirement age. There were strong indications that negative attitudes of both the elderly themselves and their general practitioners towards deafness and ageing played a crucial part in perpetuating the neglect of the disorder.

Designing trials of interventions to change professional practice in primary care: lessons from an exploratory study of two change strategies

Various strategies have been evaluated for their ability to support the adoption of clinical evidence into everyday practice.1 2 There is increasing interest in interventions aimed at groups of healthcare staff and promoting organisational change. Observational studies of these types of interventions have produced encouraging findings,3 4 but the results of randomised controlled trials have sometimes been disappointing.5–7 These differences may be due to the methodological and practical difficulties of evaluating such interventions in randomised trials rather than to lack of efficacy of the interventions.8 We carried out an exploratory trial to examine the independent and combined effects of teaching evidence based medicine and facilitated change management on the implementation of cardiovascular disease guidelines in primary care (box). The trial was accompanied by a formative evaluation, drawing on information collected by the evidence based medicine tutor, the change management facilitator, and a qualitative researcher who observed workshops and meetings and conducted a series of semistructured interviews with study participants.14 Progress was reviewed at monthly steering group meetings, and the thesis of this paper emerged from the deliberations and discussions of this group. #### Summary points When designing trials of interventions to change professional practice in primary care, choices have to be made about selection of appropriate practices, development and adaptation of interventions, and experimental design The different priorities of researchers, those developing the interventions, and those participating must be recognised when such choices are made The best design options may be those that are able to reconcile the interests of research, development, and practice Interventions requiring the participation of health professionals in organisational change require a high degree of motivation, and eligibility criteria should be developed and applied at recruitment Interventions must be adapted as far as possible to the needs of participants without compromising theoretical …

Place of medical qualification and outcomes of UK General Medical Council “fitness to practise” process: cohort study

Objectives To evaluate whether country of medical qualification is associated with “higher impact” decisions at different stages of the UK General Medical Council’s (GMC’s) “fitness to practise” process after allowing for other characteristics of doctors and inquiries. Design Retrospective cohort study. Setting Medical practice in the United Kingdom. Participants 7526 inquiries to the GMC concerning 6954 doctors. Main outcome measures Proportion of inquiries referred for further investigation at initial triage by the GMC, proportion of inquiries investigated that were subsequently referred for adjudication, and proportion of inquiries resulting in doctors being erased or suspended from the medical register; relative odds of higher impact decisions, by country of qualification, adjusted for doctors’ sex, years since primary medical qualification, medical specialty, source and type of inquiry, and nature of allegations. Results Of 7526 inquiries, 4702 concerned doctors who qualified in the UK, 624 concerned doctors who qualified elsewhere in the European Union (EU), and 2190 concerned doctors who qualified outside the EU. At the initial triage, 30% (n=1398) of inquiries concerning doctors who qualified in the UK had a high impact decision, compared with 43% (267) for doctors who qualified elsewhere in the EU and 46% (998) for those who qualified outside the EU. The adjusted relative odds of an inquiry being referred for further investigation were 1.67 (95% confidence interval 1.28 to 2.17) for doctors who qualified elsewhere in the EU and 1.61 (1.38 to 1.88) for those who qualified outside the EU, compared with doctors who qualified in the UK. At the investigation stage, 5% (228) of inquiries received concerning UK qualified doctors were referred for adjudication, compared with 10% for EU (63) or non-EU (221) qualified doctors. The adjusted relative odds of referral for adjudication were 2.14 (1.46 to 3.16) for doctors who qualified elsewhere in the EU and 1.68 (1.31 to 2.16) for those who qualified outside the EU. At the adjudication stage, 1% (69) of inquiries received concerning UK qualified doctors led to erasure or suspension, compared with 4% (24) for doctors who qualified elsewhere in the EU and 3% (71) for non-EU qualified doctors. The adjusted relative odds of erasure or suspension were 2.16 (1.22 to 3.80) for doctors who qualified elsewhere in the EU and 1.48 (1.00 to 2.19) for those who qualified outside the EU. Conclusions Inquiries to the GMC concerning doctors qualified outside the UK are more likely to be associated with higher impact decisions at each stage of the fitness to practice process. These associations were not explained by measured inquiry related and doctor related characteristics, but residual confounding cannot be excluded.

Assessment and Remediation for Physicians with Suspected Performance Problems: An International Survey.

Introduction: Little is known about the overall appropriateness and value of the various programs available internationally for assessment and remediation for individual physicians whose performance in their clinical practice has been identified as giving cause for concern. Method: A questionnaire was e‐mailed to members of the International Physicians Assessment Coalition and/or the Coalition for Physician Enhancement—organizations that were thought to provide this type of assessment (n = 20). Questions covered the aims, organization, methods, and outcomes of assessment programs and associated remediation. Results: Responses came from 15 regulatory bodies, universities, not‐for‐profits, and health service organizations in 5 countries. The assessment programs and remediation activities identified were small in scale. Their focus ranged from a narrow concern with identifying and repairing specific knowledge and skills deficits to a wider interest in the biopsychosocial functioning of the physician as a whole. Both “diagnosis” and “treatment” of problems focused on the individual physician. Less attention was given to broader systems or contextual factors that might impact performance. Although progress through remediation was carefully monitored, none of the programs undertook regular systematic follow‐up to ascertain the success of their interventions in the longer term. Discussion: This field of activity is characterized by the use of sophisticated methods for measuring performance/competence, but provision of remediation is more patchy and variable. The small scale of these programs raises questions about the relationship between scale of provision and potential need for remediation. Gaps in information about impact and outcomes mean that the overall impact and value of this type of assessment and remediation is hard to determine.

Human resources policies and continuity of care

Explores the implications for continuity of care of the wide range of policy initiatives currently affecting the management and use of human resources in the UK National Health Service. Draws on the findings of a short study undertaken in 2001 comprising a policy document analysis and a series of expert seminars discussing the impact of the policies in practice. A variety of potential long-term gains for continuity of care were identifiable in the current raft of policy initiatives and seminar participants agreed that, when these policies are fully implemented, continuity of care should be enhanced in several ways. However, the impact to date has been rather more equivocal because of the damaging effects of the process of policy implementation on continuity within the system and on staff attitudes and values. If continuity of care is accepted as an important element of quality in health care, more attention must be given to developing strategies which support system continuity.

The social dimensions of safety incident reporting in maternity care: The influence of working relationships and group processes

Over the past twenty years there has been a growing awareness of the scale and cost of adverse events in health care. In this paper we discuss findings from a study, undertaken in 2008, investigating social and cultural influences on incident reporting in maternity care in one U.K. National Health Service hospital. Maternity claims account for 50% of NHS compensation expenditure, with claims arising from poor fetal heart monitoring alone amounting to £85.8 million in 2010. Earlier studies on incident reporting used case note review and staff self-reports. We used ethnographic methods to highlight the social nature of, and social processes around, incident reporting, and the use of the collegial work group as an aid to decision-making. Incident reporting was rarely an isolated, private event, but the result of a process involving group deliberation. We suggest that incident reporting in health care should be regarded as a process rather than an event and reporting policies adjusted to accommodate group processes in order to improve reporting rates. While the paper presents findings from a single site we suggest these may add to the understanding of reporting in other care areas of health care. The key contribution this paper makes is to report the existence of a process of worker peer conferral as a decision-making aid prior to incident reporting.

Use of clinical targets in diabetes patient education: qualitative analysis of the expectations and impact of a structured self-management programme in Type 1 diabetes.

To explore the impact of education and target‐setting on the life stories of patients with diabetes up to 10 years after they had participated in the Dose Adjustment for Normal Eating programme (DAFNE).

Gathering data for health care regulation: learning from experience in England and Wales

Objectives: Between 2000 and 2004, the Commission for Health Improvement (CHI) undertook a comprehensive programme of reviews of progress with clinical governance in National Health Service trusts (provider organizations) in England and Wales. An internal retrospective evaluation of the main instruments and processes used to gather evidence for these reviews was undertaken to identify lessons for the future development of health care regulation methods. Methods: A multimethod retrospective study involving review of data-gathering tools previously undertaken by CHI, an intranet-based survey and confidential interviews with CHI staff. The study reviewed 11 instruments and processes used to gather information about trusts from routine data-sets, internal documents, staff, patients and the public, local statutory bodies, and community and voluntary stake-holders. Analysis focused on inputs required (skills and resources required to use the approaches effectively and challenges associated with their use) and value obtained (relevance and quality of the information obtained and its contribution to clinical governance review conclusions). Results/conclusions: Most of the instruments and processes evaluated had the potential to elicit worthwhile information for clinical governance reviews, but in practice their value varied considerably. A range of factors, within and beyond CHI, was found to affect the quality of the data obtained. Based on this learning, lessons are identified whose implementation would help optimize the quality of data gathering for health care regulation.

Implementation of the care programme approach across health and social services for dual diagnosis clients

Background: Care for clients with mental health problems and concurrent intellectual disability (dual diagnosis) is currently expected to be provided through the care programme approach (CPA), an approach to provide care to people with mental health problems in secondary mental health services. When CPA was originally introduced into UK mental health services in the 1990s, its implementation was slow and problematic, being hampered in part by problems occurring at a strategic level as health and social service organizations attempted to integrate complex systems. This article reports on a study of a more recent attempt to implement CPA for dual diagnosis clients in one mental health foundation trust, aiming to gauge progress and identify factors at the strategic level that were helping or hindering progress this time round. Methods: The study took place in a mental health National Health Service (NHS) Foundation Trust in a large English city, which was implementing a joint mental health and intellectual disability CPA policy across five of its constituent boroughs. Semi-structured interviews with key informants at Trust and borough levels focused on the Trust’s overall strategy for implementing CPA and on how it was being put into practice at the front line. Documentary analysis and the administration of the Partnership Assessment Tool were also undertaken. Data were analysed using a framework approach. Results: Progress in implementing CPA varied but overall was extremely limited in all the boroughs. The study identified six key contextual challenges that significantly hindered the implementation progress. These included organizational complexity; arrangements for governance and accountability; competing priorities; financial constraints; high staff turnover and complex information and IT systems. The only element of policy linked to CPA that had been widely taken up was the Greenlight Framework and Audit Toolkit (GLTK). The fact that the toolkit had targets and penalties associated with its implementation appeared to have given it priority. Conclusion: None of the contextual challenges identified in this study were specifically related to CPA as a policy or to the needs and circumstances of dual diagnosis clients. Nevertheless, they inhibited the types of organizational change and partnership working that implementing CPA for a client group of this kind required. Unless these more generic factors are acknowledged and addressed when introducing policies such as CPA, the chances of effective implementation will inevitably be compromised.