Non-medical practitioners in the staffing of emergency departments and urgent treatment centres in England: a mixed qualitative methods study of policy implementation.

BACKGROUND: Patient demand, internationally, on emergency departments and urgent care treatment centres has grown. Shortages of staff, particularly of emergency medicine doctors, have compounded problems. Some countries are pursuing solutions of including non-medical practitioners e.g., nurse practitioners and physician associates/assistants in their emergency department workforces. This study investigated at the macro and meso level of the health system in England: what the rationale was and the factors influencing the current and future employment, or otherwise, of non-medical practitioners in emergency departments and urgent treatment centres. METHODS: Mixed qualitative methods in the interpretative tradition were employed. We undertook, in 2021-2022, a documentary analysis of national, regional and subregional policy (2017-2021), followed by semi-structured interviews of a purposive sample (n = 18) of stakeholders from national, regional and subregional levels. The data were thematically analysed and then synthesised. RESULTS: There was general national policy support for increasing the presence of non-medical practitioners as part of the solution to shortages of emergency medicine doctors. However, evidence of policy support dissipated at regional and subregional levels. There were no published numbers for non-medical practitioners in emergency departments, but stakeholders suggested they were relatively small in number, unevenly distributed and faced uncertain growth. While the experience of the COVID-19 pandemic and its aftermath were said to have made senior decision makers more receptive to workforce innovation, many factors contributed to the uncertain growth. These factors included: limited evidence on the relative advantage of including non-medical practitioners; variation in the models of service being pursued to address patient demand on emergency departments and the place of non-medical practitioners within them; the lack of a national workforce plan with clear directives; and the variation in training for non-medical practitioner roles, combined with the lack of regulation of that level of practice. CONCLUSIONS: We identified many features of a system ready to introduce non-medical practitioners in emergency departments and urgent treatment centres but there were uncertainties and the potential for conflict with other professional groups. One area of uncertainty was evidence of relative advantage in including non-medical practitioners in staffing. This requires urgent attention to inform decision making for short- and long-term workforce planning. Further investigation is required to consider whether these findings are generalisable to other specialties, and to similar health systems in other countries.

Medicalisation, pharmaceuticalisation, or both? Exploring the medical management of sleeplessness as insomnia.

In this paper we examine the medical management of sleeplessness as 'insomnia', through the eyes of general practitioners (GPs) and sleep experts in Britain. Three key themes were evident in the data. These related to (i) institutional issues around advocacy and training in sleep medicine (ii) conceptual issues in the diagnosis of insomnia (iii) and how these played out in terms of treatment issues. As a result, the bulk of medical management occurred at the primary rather than secondary care level. These issues are then reflected on in terms of the light they shed on relations between the medicalisation and the pharmaceuticalisation of sleeplessness as insomnia. Sleeplessness, we suggest, is only partially and problematically medicalised as insomnia to date at the conceptual, institutional and interactional levels owing to the foregoing factors. Much of this moreover, on closer inspection, is arguably better captured through recourse to pharmaceuticalisation, including countervailing moves and downward regulatory pressures which suggest a possible degree of depharmaceuticalisation in future, at least as far prescription hypnotics are concerned. Pharmaceuticalisation therefore, we conclude, has distinct analytical value in directing our attention, in this particular case, to important dynamics occurring within if not beyond the medicalisation of sleeplessness as insomnia.

Shedding new light on the (in)compatibility of chronic disease management with everyday life - social practice theory, mobile technologies and the interwoven time-spaces of teenage life.

This article uses a socio-material approach, social practice theory, to provide new insights into the self-management of chronic illness. It demonstrates how this theory can bridge arguments about the respective roles of social and individual influences, and how it can foreground an oft-overlooked aspect of the issue - the demands of self-care technologies and consequences for participation in social life. Drawing on interviews and focus groups with 25 young type-1 diabetes outpatients in London, UK, the study points to the conflicts that occur when disease management technologies compete for time and space with the social practices of everyday life, and when self-care tasks threaten to interrupt the flow of social life and make people feel 'left behind'. The paper concludes that young people are disabled by the contingent position of self-care activities in daily life, which oblige them to compromise either their physical health or their immersion in the social world. This disabling effect would be mitigated if social practices were reorganised to make them more amenable to the time-space requirements of disease management. A social practice theory lens can help throw light onto this issue and make a valuable contribution to the study of the self-management of chronic illness.

Professional autonomy and surveillance: the case of public reporting in cardiac surgery.

Professional autonomy has come under greater scrutiny due to managerialism, consumerism, information and communication technologies (ICT), and the changing composition of professions themselves. This scrutiny is often portrayed as a tension between professional and managerial logics. Recently, medical autonomy has increasingly been shaped in terms of transparency, where publication of clinical performance (via ICT) might be a more pervasive form of surveillance. Such transparency may have the potential for a more explicit managerial logic but is contested by clinicians. This paper applies notions of surveillance to public reporting of cardiac surgery, involving the online publication of mortality rates of named surgeons. It draws on qualitative data from a case-study of cardiac surgeons in one hospital, incorporating interviews with health care managers and national policymakers in England. We examine how managerial logics are mediated by professional autonomy, generating patterns of enrolment, resistance and reactivity to public reporting. The managerial 'gaze' of public reporting is becoming widespread but the surgical specialty is accommodating it, leading to a re-assertion of knowledge, based on professional definitions. The paper assesses whether this form of surveillance is challenging to or being assimilated by the medical profession, thereby recasting the profession itself.

Managing Stigma: Young People, Asthma, and the Politics of Chronic Illness.

In this article, we explore the relationship between asthma and stigma, drawing on 31 interviews with young people (aged 5-17) in Ireland. Participants with mild to moderate asthma were recruited from Traveller and middle-class settled communities. Themes derived from an abductive approach to data analysis and a critical appreciation of Goffmanesque sociology include asthma as a discreditable stigma, negative social reactions (real, imagined, and anticipated), and stigma management. Going beyond a personal tragedy model, we reflect upon macro-social structures (e.g., ethnicity, class, gender) which underlie stigma and the management of a potentially spoiled identity. This raises issues about the politics of chronic illness, embodying health identities and efforts to tackle stigma in neoliberal times.

Patients' experiences of consultations with physician associates in primary care in England: A qualitative study.

BACKGROUND: Physician associates are new to English general practice and set to expand in numbers. OBJECTIVE: To investigate the patients' perspective on consulting with physician associates in general practice. DESIGN: A qualitative study, using semi-structured interviews, with thematic analysis. SETTING AND PARTICIPANTS: Thirty volunteer patients of 430 who had consulted physician associates for a same-day appointment and had returned a satisfaction survey, in six general practices employing physician associates in England. FINDINGS: Some participants only consulted once with a physician associate and others more frequently. The conditions consulted for ranged from minor illnesses to those requiring immediate hospital admission. Understanding the role of the physician associate varied from 'certain and correct' to 'uncertain', to 'certain and incorrect', where the patient believed the physician associate to be a doctor. Most, but not all, reported positive experiences and outcomes of their consultation, with some choosing to consult the physician. Those with negative experiences described problems when the limits of the role were reached, requiring additional GP consultations or prescription delay. Trust and confidence in the physician associate was derived from trust in the NHS, the general practice and the individual physician associate. Willingness to consult a physician associate was contingent on the patient's assessment of the severity or complexity of the problem and the desire for provider continuity. CONCLUSION: Patients saw physician associates as an appropriate general practitioner substitute. Patients' experience could inform delivery redesign.

Physician associates working in secondary care teams in England: Interprofessional implications from a national survey.

Physician associates (PAs) are a new type of healthcare professional to the United Kingdom; however, they are well established in the United States (where they are known as physician assistants). PAs are viewed as one potential solution to the current medical workforce doctor shortage. This study investigated the deployment of PAs within secondary care teams in England, through the use of a cross-sectional electronic, self-report survey. The findings from 14 questions are presented. Sixty-three PAs working in a range of specialties responded. A variety of work settings were reported, most frequently inpatient wards, with work generally taking place during weekdays. Both direct and non-direct patient care activities were reported, with the type of work undertaken varying at times, depending on the presence or absence of other healthcare professionals. PAs reported working within a variety of secondary care team staffing permutations, with the majority of these being interprofessional. Line management was largely provided by consultants; however day-to-day supervision varied, often relating to different work settings. A wide variation in ongoing supervision was also reported. Further research is required to understand the nature of PAs' contribution to collaborative care within secondary care teams in England.

Diet and identity: being a good parent in the face of contradictions presented by the ketogenic diet.

The ketogenic diet is a high-fat diet used to treat drug-resistant childhood epilepsy. Given that negative meanings tend to be attached to fatty foods and children's food consumption is seen to be the responsibility of parents, the ketogenic diet may be problematic for parenting identity. This article draws upon in-depth semi-structured interviews with 12 parents from 10 families that have a child whose epilepsy is being treated with the ketogenic diet. The main focus of the article is the meanings these parents attached to foods and how they were drawn upon or altered to overcome some of the contradictions presented by the diet. It will be argued that the diet was medicalised and parents came to view food as medicine. When viewing food in this way, negative associations with fat were reversed. Furthermore, parents also used food as a symbol of inclusion and prioritised portion size or the child's enjoyment of food in order to use food as a symbol of love. In turn this enabled parents to feel they were being good parents. Overall, it seems that diet can be medicalised and the identity of the good parent maintained if dietary treatment is successful.

Violence in general practice: a gendered risk?

This article focuses on the extent to which violence against family doctors in England is experienced in gendered terms. It draws on data from two studies: a postal survey of 1,300 general practitioners (GPs) (62% response rate) and in-depth interviews with 26 doctors who have been assaulted or threatened; and 13 focus groups with primary care teams and 19 in-depth interviews with GPs who had expressed an interest in the topic of violence against doctors. Most GPs, regardless of gender, reported receiving verbal abuse over the last two years, often interpreted as a consequence of declining deference to professionals, while actual physical assaults and threats were much rarer and more likely to be reported by men. Overall, women GPs were much more likely to express concern about violence and to take personal precautions, although younger male GPs working in inner-city practices also had high levels of concern. The study shows how some aspects of family doctors' work has been organised on gendered lines and how these contribute to the differences in experience of violence. We suggest that the increasing proportion of women among family doctors may have implications for these, often tacit, organisational routines.

Prescriptions and proscriptions: moralising sleep medicines.

The pharmaceuticalisation of sleep is a contentious issue. Sleep medicines get a 'bad press' due to their potential for dependence and other side effects, including studies reporting increased mortality risks for long-term users. Yet relatively little qualitative social science research has been conducted into how people understand and negotiate their use/non-use of sleep medicines in the context of their everyday lives. This paper draws on focus group data collected in the UK to elicit collective views on and experiences of prescription hypnotics across different social contexts. Respondents, we show, drew on a range of moral repertoires which allowed them to present themselves and their relationships with hypnotics in different ways. Six distinct repertoires about hypnotic use are identified in this regard: the 'deserving' patient, the 'responsible' user, the 'compliant' patient, the 'addict', the 'sinful' user and the 'noble' non user. These users and non-users are constructed drawing on cross-cutting themes of addiction and control, ambivalence and reflexivity. Such issues are in turn discussed in relation to recent sociological debates on the pharmaceuticalisation/de-pharmaceuticalisation of everyday life and the consumption of medicines in the UK today.

Chronic illness as biographical contingency? Young people's experiences of asthma.

Much research on chronic illness, which views the experience as disruptive, is adult-focused though there is an emerging literature on children's and young people's experiences. Drawing on 31 interviews conducted with young people diagnosed with asthma in south-west Ireland, this article contributes to this literature. The sample includes boys (n = 15) and girls (n = 16) aged between 5 and 17 from the Irish Traveller community and the larger settled community. The study also explores the potential value of what might be called biographical contingency. This concept refers to the way in which a chronic illness may be an 'only sometimes' problem and takes account of the 'now you see it, now you don't' nature of a condition that varies in terms of its symptoms, meanings and consequences. In concluding, we consider the uses and limitations of this concept and the interpretivist paradigm that typically informs qualitative research on the illness experience.

Home as a hybrid centre of medication practice.

This article presents research that explores how medications are understood and used by people in everyday life. An intensive process of data collection from 55 households was used in this research, which included photo-elicitation and diary-elicitation interviews. It is argued that households are at the very centre of complex networks of therapeutic advice and practice and can usefully be seen as hybrid centres of medication practice, where a plethora of available medications is assimilated and different forms of knowledge and expertise are made sense of. Dominant therapeutic frameworks are tactically manipulated in households in order for medication practices to align with the understandings, resources and practicalities of households. Understanding the home as a centre of medication practice decentralises the role of health advisors (whether mainstream or alternative) in wellness practices.

The contribution of physician assistants in primary care: a systematic review.

BACKGROUND: Primary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). OBJECTIVE: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems. METHODS: Medline, CINAHL, PsycINFO, BNI, SSCI and SCOPUS databases were searched from 1950 to 2010. ELIGIBILITY CRITERIA: PAs with a recognised PA qualification, general practice/family medicine included and the findings relevant to it presented separately and an English language journal publication. Two reviewers independently identified relevant publications, assessed quality using Critical Appraisal Skills Programme tools and extracted findings. Findings were classified and synthesised narratively as factors related to structure, process or outcome of care. RESULTS: 2167 publications were identified, of which 49 met our inclusion criteria, with 46 from the United States of America (USA). Structure: approximately half of PAs are reported to work in primary care in the USA with good support and a willingness to employ amongst doctors. PROCESS: the majority of PAs' workload is the management of patients with acute presentations. PAs tend to see younger patients and a different caseload to doctors, and require supervision. Studies of costs provide mixed results. OUTCOMES: acceptability to patients and potential patients is consistently found to be high, and studies of appropriateness report positively. Overall the evidence was appraised as of weak to moderate quality, with little comparative data presented and little change in research questions over time. LIMITATIONS: identification of a broad range of studies examining 'contribution' made meta analysis or meta synthesis untenable. CONCLUSIONS: The research evidence of the contribution of PAs to primary care was mixed and limited. However, the continued growth in employment of PAs in American primary care suggests that this professional group is judged to be of value by increasing numbers of employers. Further specific studies are needed to fill in the gaps in our knowledge about the effectiveness of PAs' contribution to the international primary care workforce.

Does telemonitoring in heart failure empower patients for self-care? A qualitative study.

AIMS AND OBJECTIVES: To explore the extent to which telemonitoring in patients with heart failure empowers them to self-care. BACKGROUND: Telemonitoring is increasingly used to provide structured follow-up. In patients with heart failure it has been shown to reduce mortality. However there is limited knowledge of the extent to which it supports the patient to develop self-care skills. DESIGN: A qualitative study including interviews with patients at 2 time-points. METHODS: Fifteen patients mean age 74, 11 (73%) male, 9 (60%) symptomatic on moderate activity, 6 (40%) symptomatic on mild exertion were interviewed at two time points: firstly following three months of telemonitoring and the second interview following six months of telemonitoring. Thematic analysis of the data was undertaken using constant comparison. RESULTS: Patients undertook a variety of self-care actions. During the three-month interview technological skills featured highly in patients accounts and they used telemonitoring to facilitate professional monitoring. However, during the six-month interview patients described how they used telemonitoring to support their self-care actions. Such actions were based on the understanding of heart failure that patients developed from their personal experience of symptoms, and their interaction with the telemonitoring and the telemonitoring nurse. We found no difference in self-care actions regardless of patients age, severity of their heart failure, time since diagnosis with heart failure or living alone. CONCLUSION: In summary, the majority of patients used telemonitoring daily and developed self-care skills in monitoring their heart failure. Such skills were developed over the six-month time-period of the study. RELEVANCE TO CLINICAL PRACTICE: Our findings suggest how the nurse can help patients to use telemonitoring to develop their understanding of their heart failure and empower them for self- care decision making.

The pharmaceuticalisation of society? A framework for analysis.

Drawing on insights from both medical sociology and science and technology studies this article provides a critical analysis of the nature and status of pharmaceuticalisation in terms of the following key dimensions and dynamics: (i) the redefinition or reconfiguration of health 'problems' as having a pharmaceutical solution; (ii) changing forms of governance; (iii) mediation; (iv) the creation of new techno-social identities and the mobilisation of patient or consumer groups around drugs; (v) the use of drugs for non-medical purposes and the creation of new consumer markets; and, finally, (vi) drug innovation and the colonisation of health futures. Pharmaceuticalisation, we argue, is therefore best viewed in terms of a number of heterogeneous socio-technical processes that operate at multiple macro-levels and micro-levels that are often only partial or incomplete. The article concludes by drawing out some broader conceptual and reflexive issues this raises as to how we might best understand pharmaceuticalisation, based on our analysis, as a framework for future sociological work in this field.

Disclosing clinical performance: the case of cardiac surgery.

PURPOSE: In recent years, the clinical performance of named cardiac surgeons in England has been disclosed. This paper aims to explore the nature and impact of disclosure of clinical performance. DESIGN/METHODOLOGY/APPROACH: The paper draws on literature from across the social sciences to assess the impact of disclosure, as a form of transparency, in improving clinical performance. Specifically, it employs the "programme theory" of disclosure. FINDINGS: The "programme theory" of disclosure involves identification, naming, public sanction and recipient response. Named individual (consultant) surgeons have been identified through disclosure but this masks the contribution of the clinical team, including junior surgeons. Mortality is the prime performance measure but given low mortality rates, there are problems interpreting this measure. The naming of surgeons has been achieved through disclosure on web sites, developed between the health-care regulator and the surgical profession itself. However, participation remains voluntary. The intention of disclosure is that interested parties (especially patients) will shun poorly performing surgeons. However, these parties' willingness and ability to exercise this sanction appears limited. Surgeons' responses are emergent but about a quarter of surgeons are not participating currently. Fears that surgeons would avoid high-risk patients seem to have been unrealised. While disclosure may have a small effect on individual reputations, the surgical profession as a whole has embraced disclosure. ORIGINALITY/VALUE: While the aim of disclosure has been to create a transparent medical system and to improve clinical performance, disclosure may have the opposite effect, concealing some performance issues and possibly strengthening professional autonomy. Disclosure therefore represents greater transparency in health-care but it is uncertain whether it will improve performance in the ways that the policy intends.

Beyond the orthodox/CAM dichotomy: Exploring therapeutic decision making, reasoning and practice in the therapeutic landscapes of elite sports medicine.

Elite athletes face extreme challenges to perform at peak levels. Acute and chronic musculoskeletal injuries are an occupational hazard while pressures to return to play post-injury are commonplace. Therapeutic options available to elite athletes range from novel 'cutting edge' biomedical therapies, established biomedical and surgical techniques, and physiotherapy, to a variety of non-orthodox therapies. Little is known about how different treatment options are selected, evaluated, nor how their uses are negotiated in practice. We draw on data from interviews with 27 leading sports medicine physicians working in professional football and cycling in the UK, collected 2014-16. Using idea of the 'therapeutic landscape' as a conceptual frame, we discuss how non-orthodox tools, technologies and/or techniques enter the therapeutic landscape of elite sports medicine, and how the boundaries between orthodox and non-orthodox therapy are conceptualised and navigated by sports medicine practitioners. The data provide a detailed and nuanced examination of heterogenous therapeutic decision -making, reasoning and practice. Our data show that although the biomedical paradigm remains dominant, a wide range of non-orthodox therapies are frequently used, or authorised for use, by sports medicine practitioners, and this is achieved in complex and contested ways. Moreover, we situate debates around nonorthodox medicine practices in elite sports in ways that critically inform current theories on Complementary and Alternative Medicine (CAM)/biomedicine. We argue that existing theoretical concepts of medical pluralism, integration, diversity and hybridisation, which are used to explain CAMs through their relationships with biomedicine, do not adequately account for the multiplicity, complexity and contestation that characterise contemporary forms of CAM use in elite sport.

Life Expectancy of White and Non-White Elite Heavyweight Boxers.

BACKGROUND: In post-industrial countries, ethnic minorities suffer poorer health and premature deaths. The present study examined ethnic differences in life expectancy and related features among elite heavyweight boxers. METHODS: Dates of birth and death, anthropometry, and championship years were gathered from media archives for champions and challengers (never been a champion) between years 1889 and 2019. Cox regression adjusted for age at contest, nationality, BMI, champion/challenger status, and number of contests was used to assess survival. RESULTS: All 237 boxers, 83 champions (37.3% whites) and 154 challengers (61.0% whites), who contested for heavyweight championships were identified. By 2019, 110 (75 whites, 34 non-whites) were known to have died. Non-white boxers died at an earlier age than whites boxers (mean ± SD = 59.8 ± 14.2 years versus 67.3 ± 16.4 years, p = 0.018) and had shorter survival: HR = 2.13 (95% CI = 1.4-3.3). Among non-white boxers, deaths were higher from neurological disorders: OR = 8.2 (95% CI = 1.3-13.5) and accidents: OR = 15.1 (95% CI = 2.3-98.2), while death from natural causes was lower: OR = 0.2 (95% CI = 0.03-0.8). After boxing careers, fewer non-white boxers had non-manual jobs (34.4% versus 71.8%) than manual (34.4% versus 19.7%) or were unemployed (28.1% versus 2.8%). Reported substance abuse was similar across ethnicity (8.0% versus 8.8%) but conviction rates were higher among non-white boxers (17.6%) than white (1.3%). CONCLUSIONS: Compared with white boxers, non-white boxers tend to die younger with excess neurological and accidental deaths, and they have lower social positions in later life. Sporting authorities should reappraise the wisdom of permitting head injuries in sport and monitor and support the health and wellbeing of sports men and women after retirement.

Comparing physician associates and foundation year two doctors-in-training undertaking emergency medicine consultations in England: a mixed-methods study of processes and outcomes.

OBJECTIVES: To compare the contribution of physician associates to the processes and outcomes of emergency medicine consultations with that of foundation year two doctors-in-training. DESIGN: Mixed-methods study: retrospective chart review using 4 months' anonymised clinical record data of all patients seen by physician associates or foundation year two doctors-in-training in 2016; review of a subsample of 40 records for clinical adequacy; semi-structured interviews with staff and patients; observations of physician associates. SETTING: Three emergency departments in England. PARTICIPANTS: The records of 8816 patients attended by 6 physician associates and 40 foundation year two doctors-in-training; of these n=3197 had the primary outcome recorded (n=1129 physician associates, n=2068 doctor); 14 clinicians and managers and 6 patients or relatives for interview; 5 physician associates for observation. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was unplanned re-attendance at the same emergency department within 7 days. SECONDARY OUTCOMES: consultation processes, clinical adequacy of care, and staff and patient experience. RESULTS: Re-attendances within 7 days (n=194 (6.1%)) showed no difference between physician associates and foundation year two doctors-in-training (OR 0.87, 95% CI 0.61 to 1.24, p=0.437). If seen by a physician associate, patients were more likely receive an X-ray investigation (OR 2.10, 95% CI 1.72 to 4.24), p<0.001), after adjustment for patient characteristics, triage severity of condition and statistically significant clinician intraclass correlation. Clinical reviewers found almost all patients' charts clinically adequate. Physician associates were evaluated as assessing patients in a similar way to foundation year two doctors-in-training and providing continuity in the team. Patients were positive about the care they had received from a physician associate, but had poor understanding of the role. CONCLUSIONS: Physician associates in emergency departments in England treated patients with a range of conditions safely, and at a similar level to foundation year two doctors-in-training, providing clinical operational efficiencies.