Does competition between hospitals improve clinical quality?: a review of evidence from two eras of competition in the English NHS

Gwyn Bevan and Matthew Skellern review evidence on the effects of hospital competition on quality of care within the English NHS and question whether they support government proposals to extend competition

The discrepancy between actual and unreported incidents of violence in a learning disability nursing service

This article is not available through ChesterRep. It can be accessed at http://www2.hud.ac.uk/hhs/mhrg/journal/discrepancy.pdfThis study reports on research carried out within the Learning Disability Division of a major Mental Health NHS Trust in the North of England, and relates to the discrepancy between the actual number of incidents of violence and aggression and those reported. The literature review demonstrated that violence is a particular issue for nurses, particularly those working in the areas of mental health and learning disability where studies have indicated that as many as one in five may be affected. A questionnaire was distributed to all learning disability nurses currently employed in the Trust, a total of 411, with a response rate in excess of 40%. The study revealed that a discrepancy does exist between actual and reported incidents of violence within the Trust. It confirmed previous claims that the predominant difficulty is cultural, violence being regarded as part of the job and non-reporting primarily revolving around perceptions of incidents being considered 'minor', not worth the time to complete the paperwork. The paper concludes that more work is needed to achieve a united, consistent approach across the NHS, in order that a high quality, accessible service for people with learning disabilities and complex needs can be delivered without violence being considered an acceptable part of the job

Guest editorial

This document is the Accepted Manuscript version of a published work that appeared in final form in Journal of Intellectual Disabilities and Offending Behaviour. To access the final edited and published work seehttp://dx.doi.org/10.1108/JIDOB-01-2016-0002 .This is the editorial for a special edition entitled 'Intellectual Disabilities: Nursing' of the Journal of Intellectual Disabilities and Offending Behaviour

The hospital as a multi-product firm: The effect of hospital competition on value-added indicators of clinical quality

There is increasing international interest in using Patient Reported Outcome Measures (PROMs) to assess health care provider performance. PROMs are a fundamental advance on existing indicators of health care quality in two respects: they equate outcomes with value added (i.e. health gain) from treatment rather than post-treatment health status, and they allow clinical quality to be measured at the level of the individual medical intervention to a far greater extent than existing failure-based indicators of quality such as mortality or readmissions. Most existing econometric studies of hospital competition and quality equate outcomes with post-treatment health status, and use mortality rates of various kinds as indicators of overall hospital performance, in spite of the fact that mortality is a relatively uncommon outcome in the spheres of hospital activity - such as elective surgery - in which competition for patients does occur. This paper contributes to the development of a value-added, multi-product conception of hospital quality by studying the impact of a major competition-promoting reform to the English NHS in 2006, in which patients were allowed to choose which hospital they attended for elective surgery, on PROMs of health gain from hip and knee replacement, groin hernia repair, and varicose vein surgery. In contrast to the existing literature, I find that the competition brought about by the introduction of patient choice of hospital may have had a negative effect on clinical quality. I put forward a theoretical framework that explains these findings, and conclude by arguing that future research should model the hospital as a multi-product firm, and capture clinical quality using value-added outcome measures

Minimising bias in the forensic evaluation of suspicious paediatric injury

In the rules of evidence in all legal jurisdictions, medical experts are required to maintain objectivity when providing opinions. When interpreting medical evidence, doctors must recognise, acknowledge and manage uncertainties to ensure their evidence is reliable to legal decision-makers. Even in the forensic sciences such as DNA analysis, implicit bias has been shown to influence how results are interpreted from cognitive and contextual biases unconsciously operating. In cases involving allegations of child abuse there has been significant exposure in the media, popular magazines, legal journals and in the published medical literature debating the reliability of medical evidence given in these proceedings. In these cases judges have historically been critical of experts they perceived had sacrificed objectivity for advocacy by having an investment in a 'side'. This paper firstly discusses the issue of bias then describes types of cognitive biases identified from psychological research applied to forensic evidence including adversarial bias, context bias, confirmation bias and explains how terminology can influence the communication of opinion. It follows with previously published guidelines of how to reduce the risk of bias compromising objectivity in forensic practices then concludes with my own recommendations of practices that can be used by child protection paediatricians and within an organisation when conducting forensic evaluations of suspicious childhood injury to improve objectivity in formulation of opinion evidence

The relevance of the Goudge inquiry to the practice of child protection/forensic paediatrics

In 2008 Ontario, Canada the Goudge Inquiry arose following increasing concerns about practices surrounding forensic pathology and the investigation of paediatric deaths. Some of the considerations and recommendations have relevance to child protection/forensic paediatricians, particularly in relation to their responsibilities in opinion formulation and as expert witnesses. By examining the Inquiry recommendations, this paper applies them in relation to child protection/forensic paediatrics by discussing forensic medicine and its legal context, how interpretation of published reports and data should be used in opinion formulation; issues of 'diagnosis' versus 'opinion'; issues specific to child protection paediatrics; quality control; aspects of report writing and terminological considerations. It concludes with an adaptation of key recommendations directly from those of Goudge, applied to the context of paediatric forensic medicine undertaken in child protection assessments

Does competition from private surgical centres improve public hospitals’ performance? Evidence from the English National Health Service

This paper examines the impact of competition from government-facilitated entry of private, specialty surgical centres on the efficiency and case mix of incumbent public hospitals within the English NHS. We exploit the fact that the government chose the location of these surgical centres (Independent Sector Treatment Centres or ISTCs) based on nearby public hospitals’ waiting times – not length of stay or clinical quality – to construct treatment and control groups that are comparable with respect to key outcome variables of interest. Using a difference-in-difference estimation strategy, we find that ISTC entry led to greater efficiency – measured by presurgery length of stay for hip and knee replacements – at nearby public hospitals. However, these new entrants took on healthier patients and left incumbent hospitals treating patients who were sicker, and who stayed in hospital longer after surgery

Effect of mineral oils on plant diseases

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Violence and under-reporting: Learning disability nursing and the impact of environment, experience and banding

This is the authors' version of an article published in the Journal of Clinical Nursing. The definitive version is available at www3.interscience.wiley.comThe study explores the implications of a survey into the discrepancy between actual and reported incidents of violence, perpetrated by service users, within the learning disability division of one mental health NHS Trust. Violence within the NHS continues to constitute a significant issue, especially within mental health and learning disability services where incidence remains disproportionately high despite the context of zero tolerance. A whole-population survey of 411 nurses working within a variety of settings within the learning disability division of one mental health NHS Trust. A questionnaire was administered to learning disability nursing staff working in community, respite, residential, assessment and treatment and medium secure settings, yielding a response rate of approximately 40%. There were distinct differences in the levels of violence reported within specific specialist services along with variation between these areas according to clinical environment, years of experience and nursing band. The study does not support previous findings whereby unqualified nurses experienced more incidents of violence than qualified nurses. The situation was less clear, complicated by the interrelationship between years of nursing experience, nursing band and clinical environment. The conclusions suggest that the increased emphasis on reducing violent incidents has been fairly successful with staff reporting adequate preparation for responding to specific incidents and being well supported by colleagues, managers and the organisation. The differences between specific clinical environments, however, constituted a worrying finding with implications for skill mix and staff education. The study raises questions about the relationship between the qualified nurse and the individual with a learning disability in the context of violence and according to specific circumstances of care delivery. The relationship is clearly not a simple one, and this group of nurses’ understanding and expectations of tolerance requires further research; violence is clearly never acceptable, but these nurses appear reluctant to condemn and attribute culpability

Migratory flight behaviour of the pollen beetle Meligethes aeneus

BACKGROUND The field ecology of the pollen beetle Meligethes aeneus and its damaging effects on oilseed rape crops are well understood. However, the flight behaviour of M. aeneus, in particular the drivers for migratory movements across the landscape, is not well studied. We combined three established methodologies; suction traps, vertical-looking radar and high-altitude aerial netting to demonstrate that M. aeneus fly at a range of altitudes at different points during its active season. RESULTS By linking evidence of high-altitude mass migration with immigration of pollen beetles into oilseed rape fields, we were able to ‘ground-truth’ the results to characterise the seasonal movements of this pest across the landscape. CONCLUSION We demonstrate that this novel combination of methodologies can advance our understanding of the population movements of pollen beetles and could provide an opportunity to develop predictive models to estimate the severity and timing of pest outbreaks