An integrated understanding of the impact of hospital at home: a mixed-methods study to articulate and test a programme theory.

BACKGROUND: Hospital at Home (HaH) provides intensive, hospital-level care in patients' homes for acute conditions that would normally require hospitalisation, using multidisciplinary teams. As a programme of complex medical-social interventions, a HaH programme theory has not been fully articulated although implicit in the structures, functions, and activities of the existing HaH services. We aimed to unearth the tacit theory from international evidence and test the soundness of it by studying UK HaH services. METHODS: We conducted a literature review (29 articles) adopting a 'realist review' approach (theory articulation) and examined 11 UK-based services by interviewing up to 3 staff members from each service (theory testing). The review and interview data were analysed using Framework Analysis and Purposive Text Analysis. RESULTS: The programme theory has three components- the organisational, utilisation and impact theories. The impact theory consists of key assumptions about the change processes brought about by HaH's activities and functions, as detailed in the organisational and utilisation theories. HaH teams should encompass multiple disciplines to deliver comprehensive assessments and have skill sets for physically delivering hospital-level processes of care in the home. They should aim to treat a broad range of conditions in patients who are clinically complex and felt to be vulnerable to hospital acquired harms. Services should cover 7 days a week, have plans for 24/7 response and deliver relational continuity of care through consistent staffing. As a result, patients' and carers' knowledge, skills, and confidence in disease management and self-care should be strengthened with a sense of safety during HaH treatment, and carers better supported to fulfil their role with minimal added care burden. CONCLUSIONS: There are organisational factors for HaH services and healthcare processes that contribute to better experience of care and outcomes for patients. HaH services should deliver care using hospital level processes through teams that have a focus on holistic and individually tailored care with continuity of therapeutic relationships between professionals and patients and carers resulting in less complexity and fragmentation of care. This analysis informs how HaH services can organise resources and design processes of care to optimise patient satisfaction and outcomes.

Governance for injury care systems in Ghana, South Africa and Rwanda: development and pilot testing of an assessment tool.

OBJECTIVES: This study aims to evaluate health systems governance for injury care in three sub-Saharan countries from policymakers' and injury care providers' perspectives. SETTING: Ghana, Rwanda and South Africa. DESIGN: Based on Siddiqi et al's framework for governance, we developed an online assessment tool for health system governance for injury with 37 questions covering health policy and implementation under 10 overarching principles of strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness of institutions, equity, effectiveness or efficiency, accountability, ethics and intelligence and information. A literature review was also done to support the scoring. We derived scores using two methods-investigator scores and respondent scores. PARTICIPANTS: The tool was sent out to purposively selected stakeholders, including policymakers and injury care providers in Ghana, Rwanda and South Africa. Data were collected between October 2020 and February 2021. PRIMARY AND SECONDARY OUTCOMES: Investigator-weighted and respondent percentage scores for health system governance for injury care. This was calculated for each country in total and per principle. RESULTS: Rwanda had the highest overall investigator-weighted percentage score (70%), followed by South Africa (59%). Ghana had the lowest overall investigator score (48%). The overall results were similar for the respondent scores. Some areas, such as participation and consensus, scored high in all three countries, while other areas, such as transparency, scored very low. CONCLUSION: In this multicountry governance survey, we provide insight into and evaluation of health system governance for trauma in three low- and middle-income countries (LMICs) in sub-Saharan Africa. It highlights areas of improvement that need to be prioritised, such as transparency, to meet the high burden of trauma and injuries in LMICs.

Barriers to equitable access to quality trauma care in Rwanda: a qualitative study.

OBJECTIVES: Using the 'Four Delay' framework, our study aimed to identify and explore barriers to accessing quality injury care from the injured patients', caregivers' and community leaders' perspectives. DESIGN: A qualitative study assessing barriers to trauma care comprising 20 in-depth semistructured interviews and 4 focus group discussions was conducted. The data were analysed thematically. SETTING: This qualitative study was conducted in Rwanda's rural Burera District, located in the Northern Province, and in Kigali City, the country's urban capital, to capture both the rural and urban population's experiences of being injured. PARTICIPANTS: Purposively selected participants were individuals from urban and rural communities who had accessed injury care in the previous 6 months or cared for the injured people, and community leaders. Fifty-one participants, 13 females and 38 males ranging from 21 to 68 years of age participated in interviews and focus group discussions. Thirty-six (71%) were former trauma patients with a wide range of injuries including fractured long bones (9, 45%), other fractures, head injury, polytrauma (3, 15% each), abdominal trauma (1, 5%), and lacerations (1, 5%), while the rest were caregivers and community leaders. RESULTS: Multiple barriers were identified cutting across all levels of the 'Four Delays' framework, including barriers to seeking, reaching, receiving and remaining in care. Key barriers mentioned by participants in both interviews and focus group discussions were: lack of community health insurance, limited access to ambulances, insufficient number of trauma care specialists and a high volume of trauma patients. The rigid referral process and lack of decentralised rehabilitation services were also identified as significant barriers to accessing quality care for injured patients. CONCLUSIONS: Future interventions to improve access to injury care in Rwanda must be informed by the identified barriers along the spectrum of care, from the point of injury to receipt of care and rehabilitation.

Organizational resilience in healthcare: a review and descriptive narrative synthesis of approaches to resilience measurement and assessment in empirical studies.

BACKGROUND: The coronavirus pandemic has had a profound impact on organization and delivery of care. The challenges faced by healthcare organizations in dealing with the pandemic have intensified interest in the concept of resilience. While effort has gone into conceptualising resilience, there has been relatively little work on how to evaluate organizational resilience. This paper reports on an extensive review of approaches to resilience measurement and assessment in empirical healthcare studies, and examines their usefulness for researchers, policymakers and healthcare managers. METHODS: Various databases (MEDLINE, EMBASE, PsycINFO, CINAHL (EBSCO host), Cochrane CENTRAL (Wiley), CDSR, Science Citation Index, and Social Science Citation Index) were searched from January 2000 to September 2021. We included quantitative, qualitative and modelling studies that focused on measuring or qualitatively assessing organizational resilience in a healthcare context. All studies were screened based on titles, abstracts and full text. For each approach, information on the format of measurement or assessment, method of data collection and analysis, and other relevant information were extracted. We classified the approaches to organizational resilience into five thematic areas of contrast: (1) type of shock; (2) stage of resilience; (3) included characteristics or indicators; (4) nature of output; and (5) purpose. The approaches were summarised narratively within these thematic areas. RESULTS: Thirty-five studies met the inclusion criteria. We identified a lack of consensus on how to evaluate organizational resilience in healthcare, what should be measured or assessed and when, and using what resilience characteristic and indicators. The measurement and assessment approaches varied in scope, format, content and purpose. Approaches varied in terms of whether they were prospective (resilience pre-shock) or retrospective (during or post-shock), and the extent to which they addressed a pre-defined and shock-specific set of characteristics and indicators. CONCLUSION: A range of approaches with differing characteristics and indicators has been developed to evaluate organizational resilience in healthcare, and may be of value to researchers, policymakers and healthcare managers. The choice of an approach to use in practice should be determined by the type of shock, the purpose of the evaluation, the intended use of results, and the availability of data and resources.

Social Determinants of Seeking and Reaching Injury Care in South Africa: A Community-Based Qualitative Study.

Background: Timely access to quality injury care saves lives and prevents disabilities. The impact of social determinants of health on the high injury prevalence in South Africa is well documented, however, evidence of their role in accessing injury care is lacking. This study explored the social determinants of seeking and reaching injury care in South Africa. Methods: This was a qualitative study involving rural and urban patients, community members, and healthcare providers in Western Cape, South Africa. Data were obtained through semi-structured interviews and focus group discussions using an interview guide informed by the four-delays framework. Inductive and deductive approaches were used for thematic analysis. Results: A total of 20 individual interviews and 5 focus group discussions were conducted. There were 28 males (individual interviews: 13; focus groups: 15) and 22 females (individual interviews: 7; focus groups: 15), and their mean age was 41 (standard deviation ±15) years. Barriers to seeking and reaching injury care cut across five social determinants of health domains: healthcare access and quality; neighbourhood and environment; social and community context; education; and economic stability. The most prominent social determinants of seeking and reaching injury care were related to healthcare access and quality, including perceived poor healthcare quality, poor attitude of healthcare workers, long waiting time, and ambulance delays. However, there was a strong interconnection between these and neighbourhood and environmental determinants such as safety concerns, high crime rates, gangsterism, lack of public transportation, and social and community factors (presence/absence of social support and alcohol use). Barriers related to education and economic stability were less prevalent. Conclusion: We found a substantial role of neighbourhood, social, and community factors in seeking and reaching injury care. Therefore, efforts aimed at improving access to injury care and outcomes must go beyond addressing healthcare factors to include other social determinants and should involve collaborations with multiple sectors, including the community, the police, the transport department, and alcohol regulation agencies.

Evaluating interventions to improve ethical decision making in clinical practice: a review of the literature and reflections on the challenges posed.

Since the 1980s, there has been an increasing acknowledgement of the importance of recognising the ethical dimension of clinical decision-making. Medical professional regulatory authorities in some countries now include ethical knowledge and practice in their required competencies for undergraduate and post graduate medical training. Educational interventions and clinical ethics support services have been developed to support and improve ethical decision making in clinical practice, but research evaluating the effectiveness of these interventions has been limited. We undertook a systematic review of the published literature on measures or models of evaluation used to assess the impact of interventions to improve ethical decision making in clinical care. We identified a range of measures to evaluate educational interventions, and one tool used to evaluate a clinical ethics support intervention. Most measures did not evaluate the key impact of interest, that is the quality of ethical decision making in real-world clinical practice. We describe the results of our review and reflect on the challenges of assessing ethical decision making in clinical practice that face both developers of educational and support interventions and the regulatory organisations that set and assess competency standards.

Colorectal cancer and synchronous liver metastases: An individual case-based qualitative study (CoSMIC-Q).

BACKGROUND: Contemporary management of colorectal cancer with synchronous liver metastases is complex. Although there is a large body of cohort data, there is no research exploring patient and clinician perspectives. This study explores the experiences and views of patients following treatment for colorectal cancer with synchronous liver metastases and the clinicians involved in their care. METHODS: This is a qualitative study based on interviews with patients who had completed treatment for colorectal cancer with synchronous liver metastases and their treating clinicians. The interviews were recorded, transcribed and analysed using thematic analysis methods. Codes were developed both horizontally regarding each interview as a standalone hermeneutic unit and vertically by scanning across interviews for specific terms. RESULTS: Four overarching themes emerged: patients' experience of initial diagnosis, involvement in treatment, views on the order of staged resections and views about research. For patients, the first consultation is critically important. Patients generally perceived sufficient autonomy in decision-making. In treatment options there is a preference for synchronous surgery balanced by an understanding of the greater risk. Patients did not want liver-first surgery due to the perceived risk of continued seeding from an in situ primary tumour. Clinicians accepted limited evidence for decision making but felt that trials of treatment sequencing were not feasible. CONCLUSIONS: This first qualitative study explores patients' perceptions in colorectal cancer with synchronous liver metastases that are not possible to obtain from quantitative data. CoSMIC-Q demonstrates the importance of incorporating patients' views into treatment planning particularly where equipoise exists in surgical sequence.

Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa.

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 ('Delays to receiving quality care'). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care.

Knowledge and understanding of cardiovascular disease risk factors in Sierra Leone: a qualitative study of patients' and community leaders' perceptions.

OBJECTIVES: Prevalence of cardiovascular disease risk factors (CVDRF) is increasing, especially in low-income countries. In Sierra Leone, there are no previous studies on the knowledge and the awareness of these conditions in the community. This study aimed to explore the knowledge and understanding of CVDRF, as well as the perceptions of the barriers and facilitators to accessing care for these conditions, among patients and community leaders in Sierra Leone. DESIGN: Qualitative study employing semistructured interviews and focus group discussions. SETTING: Urban and rural Bo District, Sierra Leone. PARTICIPANTS: Interviews with a purposive sample of 37 patients and two focus groups with six to nine community leaders. RESULTS: While participants possessed general knowledge of their conditions, the level and complexity of this knowledge varied widely. There were clear gaps in knowledge regarding the coexistence of CVDRF and their consequences, as well as the link between behavioural factors and CVDRF. An overarching theme from the data was the need to create an understanding and awareness of CVDRF in the community in order to prevent and improve management of these conditions. Cost was also seen as a major barrier to accessing care for CVDRFs. CONCLUSIONS: The knowledge gaps identified in this study highlight the need to design strategies and interventions that improve knowledge and recognition of CVDRF in the community. Interventions should specifically consider how to develop and enhance awareness about CVDRF and their consequences. They should also consider how patients seek help and where they access it.

What are physiotherapists and occupational therapists doing in services that replace acute hospital admission? A systematic review.

BACKGROUND: Alternatives to acute hospital admission are required to accommodate the increasing pressures on health services. Since physiotherapists and occupational therapists are integral to inpatient teams, they may also be integral to admission replacement services, and thus their roles in these services merit investigation. AIMS: Primarily to determine the presence and roles of physiotherapists and occupational therapists in services replacing acute hospital admission. The secondary outcome is to determine the impact of therapists in such services. METHODS: Five electronic databases were searched, with keywords related to therapy, discharge, and admission replacement. Inclusion criteria were that studies explicitly described at least one therapist role within a service replacing acute hospital admissions. Two authors independently reviewed all potentially eligible studies. Two reviewers independently assessed data extracted from included studies into a standardized data extraction form. RESULTS: Fifteen studies (3 Hospital at Home, 12 Early Supported Discharge) were included. Both clinical (eg, exercise prescription) and non-clinical (eg, organization and study outcome assessments) therapist roles were described in different admission substitution services. Some roles were only reported among teams, not individually ascribed to therapists. CONCLUSIONS: The roles of therapists in services that replace hospital admission are rarely described in detail, with wide variation in reported roles, including across service types and patient populations. This review could not determine the impact of individual therapists on patient or service-level outcomes. Future studies need to more clearly define therapist roles and impact.

Ageing, frailty and resilience in Botswana: rapid ageing, rapid change. Findings from a national working group meeting and literature review.

BACKGROUND: The demography of Botswana is rapidly changing. Successes in tackling communicable diseases and economic development increased life expectancy from 53.7 years in 2006 to 66.8 years in 2016. The prevalence of diseases associated with older age, especially chronic non-communicable diseases including diabetes, hypertension and cerebrovascular disease are suspected to have increased but accurate data are lacking. The country has high youth unemployment and national retirement is at the age of 60, which limits the opportunity to build pensions for prosperity in older age. Changes across health, social care and economic policy are needed to prepare for a future ageing population. METHODS: This article reports on the national working group meeting outputs on issues that face older people, their families, healthcare providers, and policy makers in Botswana. A collaborative working group meeting was convened in Gaborone, Botswana on 25th September 2018 by the University of Botswana and University of Birmingham, UK, to identify key challenges and opportunities for an ageing Batswana population. RESULTS: There was agreement across diverse stakeholders of a need for effective and rapid policy formation to prepare and protect the future health and economy of an ageing Batswana population with a high burden of NCDs. The main priorities for policy-makers must be social care, poverty reduction and healthcare provision, conducted in an evidence-based manner, as far as practicable. To effectively achieve this, research and high-quality data collection mechanisms are required. CONCLUSIONS: Future policy in Botswana must focus on the challenges that an ageing population brings, and development of health and care system resilience for the demographic change could be a model for healthcare policy across Southern Africa.

Internet videoconferencing for patient-clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations.

BACKGROUND: The use of internet videoconferencing in healthcare settings is widespread, reflecting the normalisation of this mode of communication in society and current healthcare policy. As the use of internet videoconferencing is growing, increasing numbers of reviews of literature are published. METHODS: The authors conducted a review of the existing reviews of literature relating to the use of internet videoconferencing for consultations between healthcare professionals and patients with long-term conditions in their own home. The review was followed with an assessment of United Kingdom National Institute for Health and Clinical Excellence guidelines for patient care in the context of common long-term illnesses to examine where videoconferencing could be implemented in line with these recommendations. RESULTS: The review of reviews found no formal evidence in favour of or against the use of internet videoconferencing. Patients were satisfied with the use of videoconferencing but there was limited evidence that it led to a change in health outcomes. Evidence of healthcare professional satisfaction when using this mode of communication with patients was limited. The review of guidelines suggested a number of opportunities for adoption and expansion of internet videoconferencing. Implementing videoconferencing in line with current evidence for patient care could offer support and provide information on using a communication channel that suits individual patient needs and circumstances. The evidence base for videoconferencing is growing, but there is still a lack of data relating to cost, ethics and safety. CONCLUSIONS: While the current evidence base for internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published. With more videoconferencing services added in more contexts, research needs to explore how internet videoconferencing can be implemented in ways that it is valued by patients and clinicians, and how it can fit within organisational and technical infrastructure of the healthcare services.

Ethical implications of digital communication for the patient-clinician relationship: analysis of interviews with clinicians and young adults with long term conditions (the LYNC study).

BACKGROUND: Digital communication between a patient and their clinician offers the potential for improved patient care, particularly for young people with long term conditions who are at risk of service disengagement. However, its use raises a number of ethical questions which have not been explored in empirical studies. The objective of this study was to examine, from the patient and clinician perspective, the ethical implications of the use of digital clinical communication in the context of young people living with long-term conditions. METHODS: A total of 129 semi-structured interviews, 59 with young people and 70 with healthcare professionals, from 20 United Kingdom (UK)-based specialist clinics were conducted as part of the LYNC study. Transcripts from five sites (cancer, liver, renal, cystic fibrosis and mental health) were read by a core team to identify explicit and implicit ethical issues and develop descriptive ethical codes. Our subsequent thematic analysis was developed iteratively with reference to professional and ethical norms. RESULTS: Clinician participants saw digital clinical communication as potentially increasing patient empowerment and autonomy; improving trust between patient and healthcare professional; and reducing harm because of rapid access to clinical advice. However, they also described ethical challenges, including: difficulty with defining and maintaining boundaries of confidentiality; uncertainty regarding the level of consent required; and blurring of the limits of a clinician's duty of care when unlimited access is possible. Paradoxically, the use of digital clinical communication can create dependence rather than promote autonomy in some patients. Patient participants varied in their understanding of, and concern about, confidentiality in the context of digital communication. An overarching theme emerging from the data was a shifting of the boundaries of the patient-clinician relationship and the professional duty of care in the context of use of clinical digital communication. CONCLUSIONS: The ethical implications of clinical digital communication are complex and go beyond concerns about confidentiality and consent. Any development of this form of communication should consider its impact on the patient-clinician-relationship, and include appropriate safeguards to ensure that professional ethical obligations are adhered to.

Colorectal cancer with Synchronous liver-limited Metastases: the protocol of an Inception Cohort study (CoSMIC).

INTRODUCTION: Colorectal cancer is the fourth most common cancer in the UK and an important cause of cancer-related death. In 20% of patients, there is metastasis to the liver or beyond at the time of diagnosis. The management of synchronous disease is complex. Conventional surgery removes the colorectal primary first, followed by chemotherapy, with resection of liver metastases as a final step. Advances in the availability and safety of liver surgery, anaesthesia and critical care have made two alternative options feasible. The first is synchronous resection of the primary and liver metastases. The second is resection of the metastatic disease as the first step, termed the reverse or liver-first approach. Currently, evidence is inadequate to inform the selection of care pathway for patients with colorectal cancer and synchronous liver-limited metastases. Specifically, optimal pathways are not defined and there is a dearth of prospectively recorded cohort-defining factors influencing treatment selection or outcome. METHODS AND ANALYSIS: Colorectal cancer with Synchronous liver-limited Metastases: an Inception Cohort (CoSMIC) is an inception cohort study of patients with a new diagnosis of colorectal cancer with synchronous liver-limited metastases. The sequence of treatment received, and factors influencing treatment decisions, will be evaluated against European Society of Medical Oncology guidelines. Clinical data will be collected, and quality of life, morbidity, mortality and long-term outcome compared for different treatment sequences adjusted for prognostic factors. Disease-free survival or progression will be measured at 1, 2 and 5 years. A nested qualitative study will ascertain patient experiences and clinician perspectives on delivery of care. ETHICS AND DISSEMINATION: The full study protocol was independently peer reviewed by Professor Kees de Jong (University of Maastricht, Holland). CoSMIC has ethical approval from the National Health Service Research Ethics Committee (14/NW/1397). Results will be disseminated to healthcare professionals and patient groups, and may be used to design a definitive trial addressing areas of equipoise in treatment pathways, as well as optimising current pathways to improve outcomes and experiences. TRIAL REGISTRATION NUMBER: NCT02456285, pre-results.

Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People: A Mixed-Methods Study (The LYNC Study).

BACKGROUND: Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues. OBJECTIVE: Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards. METHODS: We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs. RESULTS: Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches. CONCLUSIONS: As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety.

Virtue in Medical Practice: An Exploratory Study.

Virtue ethics has long provided fruitful resources for the study of issues in medical ethics. In particular, study of the moral virtues of the good doctor-like kindness, fairness and good judgement-have provided insights into the nature of medical professionalism and the ethical demands on the medical practitioner as a moral person. Today, a substantial literature exists exploring the virtues in medical practice and many commentators advocate an emphasis on the inculcation of the virtues of good medical practice in medical education and throughout the medical career. However, until very recently, no empirical studies have attempted to investigate which virtues, in particular, medical doctors and medical students tend to have or not to have, nor how these virtues influence how they think about or practise medicine. The question of what virtuous medical practice is, is vast and, as we have written elsewhere, the question of how to study doctors' moral character is fraught with difficulty. In this paper, we report the results of a first-of-a-kind study that attempted to explore these issues at three medical schools (and associated practice regions) in the United Kingdom. We identify which character traits are important in the good doctor in the opinion of medical students and doctors and identify which virtues they say of themselves they possess and do not possess. Moreover, we identify how thinking about the virtues contributes to doctors' and medical students' thinking about common moral dilemmas in medicine. In ending, we remark on the implications for medical education.

Describing team development within a novel GP-led urgent care centre model: a qualitative study.

OBJECTIVE: Urgent care centres (UCCs) co-located within an emergency department were developed to reduce the numbers of inappropriate emergency department admissions. Since then various UCC models have developed, including a novel general practitioner (GP)-led UCC that incorporates both GPs and emergency nurse practitioners (ENPs). Traditionally these two groups do not work alongside each other within an emergency setting. Although good teamwork is crucial to better patient outcomes, there is little within the literature about the development of a team consisting of different healthcare professionals in a novel healthcare setting. Our aim was therefore to describe staff members' perspectives of team development within the GP-led UCC model. DESIGN: Open-ended semistructured interviews, analysed using thematic content analysis. SETTING: GP-led urgent care centres in two academic teaching hospitals in London. PARTICIPANTS: 15 UCC staff members including six GPs, four ENPs, two receptionists and three managers. RESULTS: Overall participants were positive about the interprofessional team that had developed and recognised that this process had taken time. Hierarchy within the UCC setting has diminished with time, although some residual hierarchical beliefs do appear to remain. Staff appreciated interdisciplinary collaboration was likely to improve patient care. Eight key facilitating factors for the team were identified: appointment of leaders, perception of fair workload, education on roles/skill sets and development of these, shared professional understanding, interdisciplinary working, ED collaboration, clinical guidelines and social interactions. CONCLUSIONS: A strong interprofessional team has evolved within the GP-led UCCs over time, breaking down traditional professional divides. Future implementation of UCC models should pro-actively incorporate the eight facilitating factors identified from the outset, to enable effective teams to develop more quickly.

Staff perceptions on patient motives for attending GP-led urgent care centres in London: a qualitative study.

OBJECTIVES: General practitioner (GP)-led urgent care centres were established to meet the growing demand for urgent care. Staff members working in such centres are central in influencing patients' choices about which services they use, but little is known about staff perceptions of patients' motives for attending urgent care. We hence aimed to explore their perceptions of patients' motives for attending such centres. DESIGN: A phenomenological, qualitative study, including semistructured interviews. The interviews were analysed using thematic content analysis. SETTING: 2 GP-led urgent care centres in 2 academic hospitals in London. PARTICIPANTS: 15 staff members working at the centres including 8 GPs, 5 emergency nurse practitioners and 2 receptionists. RESULTS: We identified 4 main themes: 'Confusion about choices', 'As if increase of appetite had grown; By what it fed on', 'Overt reasons, covert motives' and 'A question of legitimacy'. The participants thought that the centres introduce convenient and fast access for patients. So convenient, that an increasing number of patients use them as a regular alternative to their community GP. The participants perceived that patients attend the centres because they are anxious about their symptoms and view them as serious, cannot get an appointment with their GP quickly and conveniently, are dissatisfied with the GP, or lack self-care skills. Staff members perceived some motives as legitimate (an acute health need and difficulties in getting an appointment), and others as less legitimate (convenience, minor illness, and seeking quicker access to hospital facilities). CONCLUSIONS: The participants perceived that patients attend urgent care centres because of the convenience of access relative to primary care, as well as sense of acuity and anxiety, lack self-care skills and other reasons. They perceived some motives as more legitimate than others. Attention to unmet needs in primary care can help in promoting balanced access to urgent care.