principles for collaborative care and support planning rcgp clinical innovation and research cent... more principles for collaborative care and support planning rcgp clinical innovation and research centre, 2015 Acknowledgements Many people have contributed to this document. We would particularly like to thank colleagues who gave their time to review the document: Adetola
Charity registration number: 1126980 All rights reserved, including the right of reproduction in ... more Charity registration number: 1126980 All rights reserved, including the right of reproduction in whole or in part in any form
We propose that strengthening citizenship could help realise some of the substantial changes that... more We propose that strengthening citizenship could help realise some of the substantial changes that are being called for in mainstream health policies. We highlight the way that current healthcare improvement agendas entail, and depend upon, large-scale and complex cultural change. But, we suggest, there is a severe limit to how far such cultural change can be engineered from above or through conventional quality improvement methods. In summary, we argue that supporting what we call 'civic culture'-a culture that encourages and enables effective citizenship-may be a precondition for bringing about policy aspirations and related improvements.
Modern medicine is one of humanity's great achievements. It improves, prolongs, and saves lives b... more Modern medicine is one of humanity's great achievements. It improves, prolongs, and saves lives by applying the biomedical and clinical sciences to the diagnosis and treatment of disease. Its strength lies in its clarity and focus, making it an easy model to explain, understand, and put into practice. People have found it powerful, beguiling, seductive even. It is not surprising that the medical model is proving so popular: it serves society well. But there's something going on out there. Increasing numbers of doctors and patients are questioning whether medicine has overstretched itself, 1 whether it is always as effective as proponents claim, and whether there are instances when the side effects and unintended consequences outweigh the benefits. This critique is not new, 2 3 but it has recently found a common voice in initiatives that transcend health systems and national borders, such as minimally disruptive medicine, 4 high integrity care, 5 and rethink health. 6
Providingintegrated care for older people with complex needs. King's Fund, 2013. www.kingsfund.or... more Providingintegrated care for older people with complex needs. King's Fund, 2013. www.kingsfund.org.uk/publications/providingintegrated-care-older-people-complex-needs 8 Royal College of General Practitioners. New coalition launched to make person-centred coordinated care a reality for people who live with long term conditions. www.rcgp.org. uk/news/2014/march/new-coalition-launched-on-long-term-conditions.aspx 9 Royal College of Physicians. Future hospital commission. 2013. www.rcplondon.ac.uk/ projects/future-hospital-Commission.
Recently, lower thrombin generation has been associated with excess bleeding post-cardiopulmonary... more Recently, lower thrombin generation has been associated with excess bleeding post-cardiopulmonary bypass (CPB). Therefore, treatment to correct thrombin generation is a potentially important aspect of management of bleeding in this group of patients. The objective of the present study was to investigate the effects of fresh frozen plasma (FFP), recombinant factor VIIa (rFVIIa), prothrombin complex concentrate (PCC) and tissue factor pathway inhibitor (TFPI) inhibition on thrombin generation when added ex vivo to the plasma of patients who had undergone cardiac surgery requiring CPB. Patients undergoing elective cardiac surgery were recruited. Blood samples were collected before administration of heparin and 30 min after its reversal. Thrombin generation was measured in the presence and absence of different concentrations of FFP, rFVIIa, PCC and an anti-TFPI antibody. A total of 102 patients were recruited. Thrombin generation following CPB was lower compared with pre-CPB (median endogenous thrombin potential pre-CPB 339 nmol/l per min, post-CPB 155 nmol/l per min, P < 0.0001; median peak thrombin pre-CPB 35 nmol/l, post-CPB 11 nmol/l, P < 0.0001). Coagulation factors and anticoagulants decreased, apart from total TFPI, which increased (55-111 ng/ml, P < 0.0001), and VWF (144-170 IU/dl, P < 0.0001). Thrombin generation was corrected to pre-CPB levels by the equivalent of 15 ml/kg FFP, 45 mg/ kg rFVIIa and 25 U/kg of PCC. Inhibition of TFPI resulted in an enhancement of thrombin generation significantly beyond pre-CPB levels. This study shows that FFP, rFVIIa, PCC and inhibition of TFPI correct thrombin generation in the plasma of patients who have undergone surgery requiring CPB. Inhibition of TFPI may be a further potential therapeutic strategy for managing bleeding in this group of patients.
It is generally accepted that valid consent must be obtained before providing invasive or risky t... more It is generally accepted that valid consent must be obtained before providing invasive or risky treatment-indeed it is a legal and ethical requirementbut there is much debate about how best to do it in clinical practice. 1 In England, the Department of Health and the General Medical Council (GMC) have provided guidance on the general principles, but there is no consensus on how much information about treatment benefits and harms should be provided, how these should be communicated, or whether, when and how information about alternative treatments should be made available. 2,3 English law remains uncertain on these issues and it is left up to healthcare organizations to determine how to do it and how to record details of what information patients have been given and what they have consented to. 4 There is no clear requirement to check that the information has been absorbed and understood and there has been surprisingly little research into the practice of informed consent that might help to clarify these issues. Recent developments in the USA encouraging the use of certified high-quality patient decision aids when obtaining informed consent may provide a useful pointer on how to progress this issue in the UK.
Clinicians have been slow to embrace support for patient self-management. To explore clinicians&a... more Clinicians have been slow to embrace support for patient self-management. To explore clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; beliefs about patient self-management and specifically assess which patient competencies clinicians believe are most important for their patients. Using items adapted from the Patient Activation Measure (PAM) as a basis, a new measure that assesses clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; beliefs about patient self-management was created using Rasch analysis. The development and testing of the new measure Clinician Support for Patient Activation Measure (CS-PAM) is described here. Primary care clinicians from the UK and the USA were recruited to participate in the survey (n = 175). The CS-PAM reliably measures clinician attitudes about the patient role in the care process. Clinicians strongly endorse that patients should follow medical advice but are less likely to endorse that patients should be able to make independent judgements or take independent actions. Endorsed to a lesser degree was the idea that patients should be able to function as a member of the care team. Least endorsed was the notion that patients should be independent information seekers. Clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; views appear to be out of step with current policy directions and professional codes. Clinicians need support to transition to understand the need to support patients as independent actors.
principles for collaborative care and support planning rcgp clinical innovation and research cent... more principles for collaborative care and support planning rcgp clinical innovation and research centre, 2015 Acknowledgements Many people have contributed to this document. We would particularly like to thank colleagues who gave their time to review the document: Adetola
Charity registration number: 1126980 All rights reserved, including the right of reproduction in ... more Charity registration number: 1126980 All rights reserved, including the right of reproduction in whole or in part in any form
We propose that strengthening citizenship could help realise some of the substantial changes that... more We propose that strengthening citizenship could help realise some of the substantial changes that are being called for in mainstream health policies. We highlight the way that current healthcare improvement agendas entail, and depend upon, large-scale and complex cultural change. But, we suggest, there is a severe limit to how far such cultural change can be engineered from above or through conventional quality improvement methods. In summary, we argue that supporting what we call 'civic culture'-a culture that encourages and enables effective citizenship-may be a precondition for bringing about policy aspirations and related improvements.
Modern medicine is one of humanity's great achievements. It improves, prolongs, and saves lives b... more Modern medicine is one of humanity's great achievements. It improves, prolongs, and saves lives by applying the biomedical and clinical sciences to the diagnosis and treatment of disease. Its strength lies in its clarity and focus, making it an easy model to explain, understand, and put into practice. People have found it powerful, beguiling, seductive even. It is not surprising that the medical model is proving so popular: it serves society well. But there's something going on out there. Increasing numbers of doctors and patients are questioning whether medicine has overstretched itself, 1 whether it is always as effective as proponents claim, and whether there are instances when the side effects and unintended consequences outweigh the benefits. This critique is not new, 2 3 but it has recently found a common voice in initiatives that transcend health systems and national borders, such as minimally disruptive medicine, 4 high integrity care, 5 and rethink health. 6
Providingintegrated care for older people with complex needs. King's Fund, 2013. www.kingsfund.or... more Providingintegrated care for older people with complex needs. King's Fund, 2013. www.kingsfund.org.uk/publications/providingintegrated-care-older-people-complex-needs 8 Royal College of General Practitioners. New coalition launched to make person-centred coordinated care a reality for people who live with long term conditions. www.rcgp.org. uk/news/2014/march/new-coalition-launched-on-long-term-conditions.aspx 9 Royal College of Physicians. Future hospital commission. 2013. www.rcplondon.ac.uk/ projects/future-hospital-Commission.
Recently, lower thrombin generation has been associated with excess bleeding post-cardiopulmonary... more Recently, lower thrombin generation has been associated with excess bleeding post-cardiopulmonary bypass (CPB). Therefore, treatment to correct thrombin generation is a potentially important aspect of management of bleeding in this group of patients. The objective of the present study was to investigate the effects of fresh frozen plasma (FFP), recombinant factor VIIa (rFVIIa), prothrombin complex concentrate (PCC) and tissue factor pathway inhibitor (TFPI) inhibition on thrombin generation when added ex vivo to the plasma of patients who had undergone cardiac surgery requiring CPB. Patients undergoing elective cardiac surgery were recruited. Blood samples were collected before administration of heparin and 30 min after its reversal. Thrombin generation was measured in the presence and absence of different concentrations of FFP, rFVIIa, PCC and an anti-TFPI antibody. A total of 102 patients were recruited. Thrombin generation following CPB was lower compared with pre-CPB (median endogenous thrombin potential pre-CPB 339 nmol/l per min, post-CPB 155 nmol/l per min, P < 0.0001; median peak thrombin pre-CPB 35 nmol/l, post-CPB 11 nmol/l, P < 0.0001). Coagulation factors and anticoagulants decreased, apart from total TFPI, which increased (55-111 ng/ml, P < 0.0001), and VWF (144-170 IU/dl, P < 0.0001). Thrombin generation was corrected to pre-CPB levels by the equivalent of 15 ml/kg FFP, 45 mg/ kg rFVIIa and 25 U/kg of PCC. Inhibition of TFPI resulted in an enhancement of thrombin generation significantly beyond pre-CPB levels. This study shows that FFP, rFVIIa, PCC and inhibition of TFPI correct thrombin generation in the plasma of patients who have undergone surgery requiring CPB. Inhibition of TFPI may be a further potential therapeutic strategy for managing bleeding in this group of patients.
It is generally accepted that valid consent must be obtained before providing invasive or risky t... more It is generally accepted that valid consent must be obtained before providing invasive or risky treatment-indeed it is a legal and ethical requirementbut there is much debate about how best to do it in clinical practice. 1 In England, the Department of Health and the General Medical Council (GMC) have provided guidance on the general principles, but there is no consensus on how much information about treatment benefits and harms should be provided, how these should be communicated, or whether, when and how information about alternative treatments should be made available. 2,3 English law remains uncertain on these issues and it is left up to healthcare organizations to determine how to do it and how to record details of what information patients have been given and what they have consented to. 4 There is no clear requirement to check that the information has been absorbed and understood and there has been surprisingly little research into the practice of informed consent that might help to clarify these issues. Recent developments in the USA encouraging the use of certified high-quality patient decision aids when obtaining informed consent may provide a useful pointer on how to progress this issue in the UK.
Clinicians have been slow to embrace support for patient self-management. To explore clinicians&a... more Clinicians have been slow to embrace support for patient self-management. To explore clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; beliefs about patient self-management and specifically assess which patient competencies clinicians believe are most important for their patients. Using items adapted from the Patient Activation Measure (PAM) as a basis, a new measure that assesses clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; beliefs about patient self-management was created using Rasch analysis. The development and testing of the new measure Clinician Support for Patient Activation Measure (CS-PAM) is described here. Primary care clinicians from the UK and the USA were recruited to participate in the survey (n = 175). The CS-PAM reliably measures clinician attitudes about the patient role in the care process. Clinicians strongly endorse that patients should follow medical advice but are less likely to endorse that patients should be able to make independent judgements or take independent actions. Endorsed to a lesser degree was the idea that patients should be able to function as a member of the care team. Least endorsed was the notion that patients should be independent information seekers. Clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; views appear to be out of step with current policy directions and professional codes. Clinicians need support to transition to understand the need to support patients as independent actors.
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