Piotr Ozieranski

Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study

Background Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS). Methods Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary. Results We found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

Pharmaceutical lobbying under postcommunism: universal or country-specific methods of securing state drug reimbursement in Poland?

This paper aims to fill in the gap in research on the effect of pharmaceutical lobbying on drug reimbursement policy, particularly in Poland, a post-communist country. To this end, we conducted in-depth, semi-structured, anonymous, elite interviews in Poland, supplemented by a review of legislation, policy documents, official reports and press articles, as well as observations. Overall, 109 representatives of stakeholders involved in reimbursement policy were interviewed. We identified two key lobbying methods: informal persuasion and third-party endorsements. These methods are coupled with two supplementary ones: lobbying through parliament and ministries, as well as diplomatic pressure. Pharmaceutical lobbying methods in Poland clearly resemble those used in other European countries. What is notable about the Polish case is extensive reliance on informal lobbying and diplomatic pressure.

How collaborative are quality improvement collaboratives: a qualitative study in stroke care

BackgroundQuality improvement collaboratives (QICs) continue to be widely used, yet evidence for their effectiveness is equivocal. We sought to explain what happened in Stroke 90:10, a QIC designed to improve stroke care in 24 hospitals in the North West of England. Our study drew in part on the literature on collective action and inter-organizational collaboration. This literature has been relatively neglected in evaluations of QICs, even though they are founded on principles of co-operation and sharing.MethodsWe interviewed 32 professionals in hospitals that participated in Stroke 90:10, conducted a focus group with the QIC faculty team, and reviewed purposively sampled documents including reports and newsletters. Analysis was based on a modified form of Framework Analysis, combining sensitizing constructs derived from the literature and new, empirically derived thematic categories.ResultsImprovements in stroke care were attributed to QIC participation by many professionals. They described how the QIC fostered a sense of community and increased attention to stroke care within their organizations. However, participants’ experiences of the QIC varied. Starting positions were different; some organizations were achieving higher levels of performance than others before the QIC began, and some had more pre-existing experience of quality improvement methods. Some participants had more to learn, others more to teach. Some evidence of free-riding was found. Benchmarking improvement was variously experienced as friendly rivalry or as time-consuming and stressful. Participants’ competitive desire to demonstrate success sometimes conflicted with collaborative aims; some experienced competing organizational pressures or saw the QIC as duplication of effort. Experiences of inter-organizational collaboration were influenced by variations in intra-organizational support.ConclusionsCollaboration is not the only mode of behavior likely to occur within a QIC. Our study revealed a mixed picture of collaboration, free-riding and competition. QICs should learn from work on the challenges of collective action; set realistic goals; account for context; ensure sufficient time and resources are made available; and carefully manage the collaborative to mitigate the risks of collaborative inertia and unhelpful competitive or anti-cooperative behaviors. Individual organizations should assess the costs and benefits of collaboration as a means of attaining quality improvement.

A pill too hard to swallow: how the NHS is limiting access to high priced drugs.

A joint investigation by The BMJ and Cambridge and Bath universities uncovers how NHS England tried to limit access to expensive new drugs for hepatitis C. Jonathan Gornall, Amanda Hoey, and Piotr Ozieranski report

Transparency in practice: Evidence from 'verification analyses' issued by the Polish Agency for Health Technology Assessment in 2012-2015.

Transparency is recognised to be a key underpinning of the work of health technology assessment (HTA) agencies, yet it has only recently become a subject of systematic inquiry. We contribute to this research field by considering the Polish Agency for Health Technology Assessment (AHTAPol). We situate the AHTAPol in a broader context by comparing it with the National Institute for Health and Care Excellence (NICE) in England. To this end, we analyse all 332 assessment reports, called verification analyses, that the AHTAPol issued from 2012 to 2015, and a stratified sample of 22 Evidence Review Group reports published by NICE in the same period. Overall, by increasingly presenting its key conclusions in assessment reports, the AHTAPol has reached the transparency standards set out by NICE in transparency of HTA outputs. The AHTAPol is more transparent than NICE in certain aspects of the HTA process, such as providing rationales for redacting assessment reports and providing summaries of expert opinions. Nevertheless, it is less transparent in other areas of the HTA process, such as including information on expert conflicts of interest. Our findings have important implications for understanding HTA in Poland and more broadly. We use them to formulate recommendations for policymakers.

Disclosure of payments by pharmaceutical companies to healthcare professionals in the UK: analysis of the Association of the British Pharmaceutical Industry’s Disclosure UK database, 2015 and 2016 cohorts

Objectives To analyse the section of Disclosure UK that pertains to healthcare professionals (HCPs) in order to provide insight into the database’s structure and content and suggest ways to improve its transparency. Design and participants Cohort study of drug companies and HCPs in the 2015 and 2016 versions of Disclosure UK. Results Companies report transfers of value (ToVs) to named HCPs or, where an HCP declines to consent, in aggregate. Only a limited number of variables describe the recipient HCP and the ToV, precluding refined analyses. In 2015, 107 companies reported 54 910 ToVs worth ₤50 967 728. In 2016, 109 companies reported ToVs but spending decreased by 7.3%. The spending was concentrated: the top 10 spenders reported about 50% of the total value, with consultancy-related payments comprising over 70%, and the rest being costs for events. In 2015, 55.5% (30 478) of ToVs worth ₤24 428 619 (47.9%) were disclosed at the individual HCP level, increasing to 64.5% (32 407) and ₤28 145 091 (59.2%) in 2016. Despite increased individual-level disclosure in 2016, the median number of ToVs reported by each company at the individual level was only 57.7%, with 25% of companies reporting less than 38.6%. We found little agreement (62%–48% in 2015 and 46%–30% in 2016) between HCP consent rates that we calculated based on information in the database and those provided by companies. Conclusions Key deficiencies in Disclosure UK include: insufficient information on payments and recipients, a relatively low HCP consent rate for individual-level disclosure, differences in consent rates across companies and payment types, and reporting ambiguities or inconsistencies. We employ these findings to develop recommendations for improving transparency, including an easily interpretable consent rate statistic that allows for comparison across years, firms and countries. If deficiencies remain unresolved, the UK should consider introducing legislation requiring mandatory disclosure to allow for adequate tracking of industry payments.

New European tricksters: Polish jokes in the context of European Union labour migration:

In the context of contemporary European labour migration, where the most publicised pattern of labour migration sees Eastern European migrants move West, the dominant scholarly interpretation of Polish jokes is not applicable for the analysis of much of the joking by or about the Poles. Humour scholars frequently categorise jokes about ethnic groups into stupid or canny categories, and the Poles have been the butt of stupidity (‘Polack’) jokes in Europe and the United States. Today, in the European Union, Polish stupidity stereotyping in humour is less active and the Polish immigrant is hard working and a threat to indigenous labour, yet joking does not depict this threat in a canny Pole. The article applies the liminal concept of the trickster – an ambiguous border crosser or traveller – to elaborate some of the characteristics of jokes told by and about Polish migrants in the EU, mainly in the British context. A more robust explanatory framework is thus offered than is currently available in humour studies.

Wales approves new hepatitis C drug while England deliberates

A new drug for hepatitis C has been approved for use in Wales ahead of its appraisal by the National Institute for Health and Care Excellence (NICE) for use in England and is being made available to patients in line with the Welsh strategy to prevent the transmission of the virus. The All Wales Medicines Strategy Group recommended Epclusa (sofosbuvir with velpatasvir) for use in the NHS in Wales after concluding that the treatment would be cost effective for most patients.1 The treatment will be funded under the Welsh patient access scheme. The price proposed by its manufacturer, Gilead, is confidential but likely to involve a discount from the UK list price of about £40 000 (€47 000;

The politics of health technology assessment in Poland.

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