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  1. T Smith,
  2. G Harvey,
  3. M Maresh,
  4. H McKenna,
  5. R Baker

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    This journal scan is based on a hand search of a number of clinical journals as well as others focusing on improvement and management for the period from December 2000 to February 2001

    Getting evidence based health care into practice

    Much of the evidence from clinical trials is based on the study of the use of interventions in specially selected groups of patients who often seem unlike many of those who seek health care. Moreover, clinical trials do not take into account the organisational circumstances in which care is given. But how much should these sort of observations influence thinking about and practice of evidence based health care? Understanding better the process by which outcomes and effectiveness research affect policy and practice may help to answer these important questions.

    Stryer D, Tunis S, Hubbard H, et al. The outcomes of outcomes and effectiveness research: impacts and lessons from the first decade. Health Serv Res 2000;35:977–95.

    Abstract reproduced from original.

    This study assesses the outcomes of the Agency for Healthcare Research and Quality's first decade of focus on outcomes and effectiveness research and identifies needs and opportunities for the study of OER in the coming years. Study findings were collected in response to an inquiry by the Center for Outcomes and Effectiveness Research at AHRQ in July 1997 to all principal investigators funded between 1989 and 1997. The request was for investigators to identify their most salient findings and supply material for up to three slides. OER has had moderate but significant success meeting initial expectations from the field. Challenges for the next generation of OER include advancing from hypothesis generation to definitive studies of effectiveness, and acceleration of the process by which findings affect policy, practice, and outcomes.

    Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001;51:303.

    Barbara Starfield's investigations of the impact of primary health care services in different health care systems are familiar. She has shown that, where primary care is strong, countries have lower health care costs. She has also been able to demonstrate a relationship between population mortality and the number of primary care physicians in the USA—apparently one extra primary care physician reduces total mortality by 34 per 100 000 people. Primary care also reduces the health consequences of income in equality. Thus, primary care appears to be a good thing. However, there are important implications for addressing the quality of care. Starfield argues that an increasingly high proportion of the population have many different illnesses. For example, she quotes work that indicates that 75% of US adults can be classified as sick because they have one or more of obesity, hypertension, diabetes and hypercholesterolaemia. One consequence is that evidence based medicine is not appropriate for primary care. Her argument is that randomised controlled trials exclude people with co-morbidity and therefore the findings of studies cannot be applied easily to the majority of the population. Furthermore, the characteristics of the health care system—including, for example, the number of primary care physicians per million of population—must be taken into account. Population characteristics should also be accounted for. There will be different reactions to Starfield's arguments and whether you accept some of them will depend to a large extent on your previous beliefs. However, it is well worth noting the shift towards monitoring outcomes in primary care and the relationship between primary care services and population mortality.

    Organisational change

    That implementation of quality management systems in Greek hospitals was largely dependent on employees' initiatives rather than central planning is yet another example of the need for grass roots involvement for effective quality improvement.

    Donald IP, Jay T, Linsell J, et al. Defining the appropriate use of community hospital beds. Br J Gen Pract 2001;51:95–100.

    “Appropriate” is a tricky word. It so easily becomes a subjective judgement rather than precise assessment. It is inevitable, therefore, that attempts to define the appropriateness of a hospital admission or day spent in a hospital bed by a patient are fraught with difficulty. In this article the authors report the development of a measure for assessing the appropriateness of use of community hospital beds. The authors started from a well established instrument used to assess the appropriateness of admissions to general hospitals. A steering group modified the instrument through a serious of pilot tests. The eventual instrument, known as CHAEP (Community Hospital Appropriateness Evaluation Protocol), was used to assess 440 admissions to community hospitals, and the findings were compared with 440 admissions to district general hospitals. Community hospitals generally serve patients with subacute illness and patients are generally managed by their family doctors. Policy makers concerned about the costs of providing health care might be anxious that admissions to community hospitals could be inappropriate. However, there were no major differences between community hospitals and district general hospitals. 75% of admissions to the general hospitals satisfied at least one of the admission criteria, and the proportion for community hospitals was 82%. The authors conclude that inappropriate bed use is less common than some managers might have anticipated. GPs with access to community hospital beds or similar facilities may like to assess the appropriateness of their use of such beds by using CHAEP.

    Theodorakioglou YD, Tsiotras GD. The need for the introduction of quality management into Greek health care. Total Qual Manage 2000;11(8).

    Abstract reproduced from original.

    This paper describes the results of research conducted in Greek public hospitals between May and October 1998. The research aims to investigate the organized and scientific implementation of quality management systems in Greek public hospitals. In most cases, the implementation of quality programs depends on employees' initiatives and does not stem from an organized, central plan.

    Savory P, Olson J. Guidelines for using process mapping to aid improvement efforts. Hosp Mater Manage Q 2001;22:10–16.

    Abstract reproduced from original.

    Process mapping is an easy-to-visualize method that allows people to analyse and agree on the most efficient routes for re-engineering or improving a process. It aids in determining redundant tasks, uncovering hidden interactions between processes and people, and focusing on the processes that serve customers, improve quality, and generate income. The study presents guidelines for using process mapping as an improvement tool. It is based on the authors' experiences in aiding a variety of health care, service, and manufacturing companies.

    User perspective/patient expectations

    Information relevant to understanding the way in which health care systems work is necessary for improving the quality of care and comes from many sources. Health care professionals have traditionally guarded information about health and health care, but it seems that our efforts to inform the public about health matters may be eclipsed by television soap operas. One of the papers in this section reports the impact of inclusion of a health related topic in the story line of “ER”. Perhaps screen writers should become part of health care teams.

    Smith H, Latimer V, George S. General practitioners' perceptions of the appropriateness and inappropriateness of out-of-hours calls. Br J Gen Pract 2001;51:270.

    This study examined the views of GPs on the appropriateness of out-of-hours calls. Every GP will have his or her story of a bizarre request for a home visit out-of-hours. Among GPs, such stories gain in the telling and become rather like “fishermen's tales”. Apparently the numbers of out-of-hours calls in recent years has been rising in the UK. The explanation is unclear, and some commentators point to rising patient expectations while others suggest that out-of-hours cooperatives and deputising services have reduced the opportunity for GPs to train their own patients to use their services with consideration. In this survey in two regions of the UK, 146 GPs gave their views of what constituted appropriate out-of-hours calls. Severe illness was, of course, regarded as appropriate, but GPs took other factors into account such as patient fear and anxiety, lack of patient mobility, young children or the elderly, and evidence that the patient had already tried some remedies themselves. Inappropriate out-of-hours calls included those for minor illness, long term problems, social problems, and convenience. Some patients were regarded as manipulative or demanding. But who should determine the appropriateness of the call out-of-hours? Should it be the GP or should it be the patient? This question reflects the transition that has taken place from the paternal practitioner of 30 years ago to the modern provider of primary care to an informed and consumerist population.

    Brodie M, Foehr U, Rideout V, et al. Communicating health information through the entertainment media. Health Aff 2001;20:192–9.

    Abstract compiled from full text.

    Co-written by an “ER” screenwriter, this study of the television drama lends support to the notion that Americans pick up information while being entertained. Many viewers surveyed increased their knowledge because of these “ER” episodes. This study documents that viewers are interested in health related story lines, and some learn about health topics and have been motivated to seek additional health information, even engaging in discussions about health issues with their friends and families, and sometimes their doctors. Importantly, this first of its kind natural experiment highlights that repetition of messages is the key to increased comprehension and longer term retention among audiences. When specific health information is presented only through a brief, one time mention, viewers' long term retention of the information is questionable. Entertainment television reaches a wide audience and, in the end, whether one feels that entertainment television does more good or more harm, it will continue to convey health information to its audience whether by design or by default. This study shows that the content has an impact on that audience. It seems, therefore, worth the effort to try to make the content as accurate and science-based as possible, and to take advantage of opportunities to convey public health messages that can improve health and sometimes save lives.

    Stewart MJ, Hart G, Mann K, et al. Telephone support group intervention for persons with hemophilia and HIV/AIDS and family caregivers. Int J Nurs Stud 2001;38:209–25.

    Abstract reproduced from original.

    The purpose of this pilot project was to test the feasibility of a telephone support group intervention for persons with haemophilia and HIV/AIDS and for their family caregivers. Their support needs were unique because they did not identify with predominant groups of persons with AIDS and were geographically dispersed from peers. The 12 week intervention involved separate telephone support groups for haemophiliacs and for family caregivers. The two groups, comprised of a predetermined maximum of six people, were co-led by a professional and a peer. The support group for family caregivers involved six people and the group for men with haemophilia included five people, including one peer facilitator and one professional facilitator in each group. The telephone support group discussions were taped, transcribed, and analysed for prevalent themes. The peer and professional facilitators maintained weekly field notes. All participants reported that the telephone groups had a positive impact on meeting their support needs. They believed that they had benefited from sharing information and that the support groups had decreased their feelings of isolation and loneliness. Participants, however, contended that the intervention should be longer than 12 weeks.

    Holtkamp CCM, Kerkstra A, Ribbe MW, et al. The relation between quality of co-ordination of nursing care and quality of life in Dutch nursing homes. J Adv Nurs 2000;32:1364–73.

    Abstract reproduced from original.

    Quality of life of nursing home residents is a critical consideration in international health care policies and health care decisions. Yet, there is little relevant research to support decisions about client-tailored and effective nursing care for this population. Because of the permanency of their stay, the care received affects the quality of daily life. This study investigated the quality of coordination of care and the way it is related to gaps between needs and care supply, the quality of life and health status of residents living in Dutch nursing homes. To assess the perceived quality of life and experienced discrepancies between needs and care supply, 337 residents of 10 different nursing homes were interviewed. The quality of coordination of nursing care was assessed by judgements of the residents and nurses and by analysing the care documents. The results showed a relation between the coordination of care and care discrepancies; the higher the quality of coordination of care, the fewer the gaps between residents' needs and the care they received. The psychosocial aspects in particular showed a gap between the needs and care supply. As regards the relation between coordination of care and quality of life, the strongest positive relations were found between taking case histories, patient allocation, and dimensions of quality of life. No direct relations were found between the coordination of care and care discrepancies on the one hand and the health status of the residents on the other. In conclusion, this study showed that the quality of coordination of care can affect the perceived quality of life of nursing home residents. To meet the residents' needs it is important to assess their physical and psychosocial needs accurately. More research focusing on this assessment is needed in order to improve the quality of life of nursing home residents.

    McGarry J, Arthur A. Informal caring in late life: a qualitative study of the experiences of older carers. J Adv Nurs 2001;33:182-9.

    Abstract adapted from original.

    Estimates suggest that 13% of those aged over 65 years are providing some form of informal care. This study set out to examine the experiences of older carers who were aged 75 years and over. Potential study participants were identified during one round of annual over 75 health checks carried out in one large general practice. 58 carers were identified and 14 were approached to take part in the study. Of these 14, 13 were caring for a spouse and one for a sibling. Data were collected through personal interviews, which were transcribed and analysed using a thematic approach. The themes emerging for the analysis were categorised under four headings: (1) the organisational demands and structure of the caring relationship, (2) informal support networks, (3) formal services, and (4) the constancy of caring and the need for the carer role to be recognised. The authors conclude that the over 75 health check may provide a valuable tool to identify older carers who are not known to be care providers and that nurses can take a lead role in working with this group in three ways: firstly, in identifying older carers; secondly, in developing strategies to assist older carers in their caring role and, finally, in responding swiftly to crises that can develop among this vulnerable group.

    Attree M. Patients' and relatives' experiences and perspectives of `good' and `not so good' quality care. J Advanced Nursing 2001;33:456–6.

    Abstract adapted from original.

    This study set out to explore patients' and relatives' perceptions of care and to identify key criteria used to evaluate the quality of care, via descriptions of actual care experiences. The study employed a qualitative methodology of Grounded Theory. Data were collected from a purposive sample of 34 acute medical patients and seven relatives using semi-structured interview methods. The resulting data were subject to question and thematic analysis. The nature of the care provided and interpersonal aspects of caring emerged as key quality issues for patients. `Good quality care' was characterised as individualised, patient focused and related to need. It was care that was provided humanistically, through the presence of a caring relationship by staff who demonstrated involvement, commitment and concern. Care described as `not so good' was routine, unrelated to need, and delivered in an impersonal manner by distant staff who did not know or involve patients. The author concluded that these findings challenge the commonly accepted view that patients place greater emphasis on the quality of the technical aspects of care. Consequently, the quality issues identified as important by patients and relatives in this study are not always evaluated in care audits. The author suggests that those responsible for evaluating health care quality should consider combining traditional (professional/technical) audit criteria with those used by health care users to achieve a more comprehensive evaluation.

    Quality improvement in practice

    Incorporating IT into the daily work of health care so that it serves and supports is a challenge. But when IT is synchronous with the human processes of care, the benefits are clear. By combining the traditional PDSA cycle with the use of electronic medical records, a CQI group in a family practice have managed to improve and sustain identification of smokers. Documentation of smoking cessation counselling also increased.

    Spencer E, Swanson T, Hueston WJ, et al. Tools to improve documentation of smoking status: continuous quality improvement and electronic medical records. Arch Fam Med 1999;8:18–22.

    Abstract reproduced from original.

    Background—Despite the deleterious effects of smoking on the nation's health and evidence that smoking cessation advice by family practice physicians is cost effective, self-sustaining office systems to identify smokers in primary care clinics have been difficult to establish. We worked on a continuous quality improvement project group, aided by an electronic medical record, to design a system to document and periodically update smoking status in a consistent place in the medical record.

    Intervention—Using the continuous quality improvement plan-do-study-act (PDSA) cycle, a seven member group worked with nursing staff to define roles, routines, and responsibilities for medical assistants to screen for and document one of four categories of smoking status in the major problem list of the electronic medical record for at least 80% of patient appointments. Screening rate was tracked monthly by means of the electronic medical record and feedback was given to staff.

    Results—The screening rate rose from 18.4% to 80.3% within 2 weeks after the system was implemented and was maintained for 19 months. An additional benefit was an increased rate of smoking cessation counselling documented by providers, from a baseline rate of 17.1% to 48.3%.

    Conclusions—A continuous quality improvement group process aided by an electronic medical record is useful to develop a self-sustaining office system to screen, document, and periodically update smoking status in a consistent place in the medical record. Although screening for and documenting smoking status are only the first step toward helping patients stop smoking, it is an important one.

    Sherwood P, Lyburn I, Brown S, et al. How are abnormal results for liver function tests dealt with in primary care? Audit of yield and impact. BMJ 2001;322:276–8.

    Abstract reproduced from original.

    Objective—To determine whether abnormal results for liver function tests are investigated in primary care and findings on full investigation.

    Design—Retrospective audit and prospective clinical investigation.

    Setting—University hospital and surrounding general practices serving around 330 000 people.

    Subjects—Adults with abnormal results for liver function based on tests requested by their doctor between 1 January and 30 June 1995.

    Interventions—All patients with γ-glutamyltransferase, alanine aminotransferase, or alkaline phosphatase concentrations at least twice the upper limit of the reference range were studied. A median of 15 months later (range 12–21) records of hospital attendances and further investigations were examined. Where investigations were incomplete the records from the general practice were examined, and suitable patients were invited to attend the liver clinic.

    Main outcome measures—Investigations requested by the doctor and final diagnoses reached.

    Results—933 patients with abnormal liver function tests were identified; follow up data were obtained in 873 (94%). 531 patients were already under hospital review. Of the remaining 342 patients, 157 were suitable for investigation; the others had died, moved away, were elderly, or had repeat liver function tests with normal results. No further tests were requested for 91 (58%) of these patients. 66 had been partially investigated by their doctor, and in seven patients results suggesting a treatable chronic liver disease had not been followed up. On investigation, 97 (62%) had an identifiable diagnosis requiring hospital intervention or follow up, or both.

    Conclusions—Abnormal results for liver function are often not adequately investigated, missing an important chance of identifying treatable chronic liver disease.

    Manias E, Street A. Legitimation of nurses' knowledge through policies and protocols in clinical practice. J Adv Nurs 2000;32:1467–75.

    Abstract reproduced from original.

    Health care professionals use policies and protocols in varying ways to guide their clinical activities and to promote quality patient care. The critical ethnographic case study, upon which this paper is based, involved a research group comprising six registered nurses who worked in a critical care setting. Research methods included professional journalling, participant observation and focus group and individual interviews. This paper examines the power relations at play between doctors and nurses, and among nurses, and the ways in which nurses used policies and protocols as a means of mediating communication. While policies and protocols provided nurses with legitimacy of their knowledge in the clinical arena, doctors tended to rely on their past experience and background to inform their knowledge and activities. For nurses to believe that they provided valued and collaborative input in patient decisions, they actively sought out written evidence through policies and protocols to confirm and support their knowledge. Policies and protocols of critical care activities provided nurses with expected standards of care, which they used to legitimise their knowledge and to communicate with doctors about `undesirable' medical decisions. The doctors valued their professional authority and autonomy over policies and protocols, while nurses used these written guidelines to assert power and demonstrate resistance. Policies and protocols do not exist in isolation; they occur within a complex network of power relations that create tensions in clinical practice. In challenging these tensions, it is important that nurses and doctors establish a fine balance between using policies and protocols to provide directions for practice, and to allow sufficient latitude and flexibility in addressing the complexities of patient care.

    Kunst P, Lemmink J. Quality management and business performance in hospitals: a search for success parameters. Total Qual Manage 2000;11(8).

    Abstract reproduced from original.

    This paper is based on the results of a European study aimed at identifying and exploring success parameters of high (quality) performance and their possible interrelationships. The study was conducted in three service sectors (the hospital, road freight transport, and banking) in three European countries (Spain, UK and the Netherlands) early in 1995. Concentration is on the hospital sector. In general, it is concluded that progress in TQM leads to higher business performance of the hospital, indicating the efficiency/cost effect, and to a higher perceived service quality by patients, indicating the effectiveness.

    Douglas TJ, Judge Jr WQ. Total quality management implementation and competitive advantage: the role of structural control and exploration. Acad Manage J 2001;44:158–69.

    Abstract reproduced from original.

    The relationship between the degree to which total quality management practices were adopted within organizations and the corresponding competitive advantages achieved are explored. Relatively strong support for this relationship is found. In addition, data showed some support for the moderating influence of organizational structure of TQM implementation effectiveness. Specifically, two measures of organizational structure, labelled “control” and “exploration”, were found to offer independence and interdependent influences on the financial performance of firms implementing TQM programs.

    Pandian Z, Ashok P, Templeton A. The treatment of incomplete miscarriage with oral misoprostol. Br J Obstet Gynaecol 2001;108:213–4.

    With at least one in five pregnancies resulting in early miscarriage, considerable health service resources are used to manage these women. For years the standard management has been to admit them to hospital and to evacuate the uterus under general anaesthesia. Over the last 10 years there has been increasing interest in the use of drug therapy to cause a complete miscarriage, with the women managed in an ambulatory care setting. 112 women who were diagnosed either clinically or on ultrasound as having an incomplete miscarriage agreed to the use of drug treatment to complete the process. Three doses of the prostaglandin analogue misoprostol were given at 2 hourly intervals. Only 13% of women needed the regime to be repeated. 85% of the women avoided the need for surgical evacuation. This is lower than the rate of success with medical termination of pregnancy using similar drugs. Medical management of incomplete miscarriage on an ambulatory care basis offers a satisfactory method of managing this distressing problem. More research is needed on regime detail and patient acceptability. Its widespread introduction would have a significant impact on the use of gynaecological inpatient hospital resources as this is the most common indication for an emergency gynaecological admission.

    Education and training

    The stresses of working in health care are well known. Finding ways to support staff and understand their concerns is crucial if they are to provide good quality care and avoid burnout. In times of staff shortages, when stresses are greatest, it is often support and supervision that are abandoned. The message from one of the papers included in this section is to make sure that the most junior staff get any support that is available; they probably need it the most and, importantly, benefit most.

    Teasdale K, Brocklehurst N, Thom N. Clinical supervision and support for nurses: an evaluation study. J Adv Nurs 2001;33:216–24.

    Abstract adapted from original.

    This study aimed to assess the effects of clinical supervision and informal support on qualified nurses. Previous small scale research studies provided conflicting evidence about the impact of clinical supervision. Consequently, this study was undertaken as a larger scale study, using a survey design which drew on an opportunity sample of 211 qualified nurses from 11 randomly selected hospital and community NHS trusts in one region in England. Quantitative data were collected using the Maslach Burnout Inventory (MBI) and the Nursing in Context Questionnaire (NICQ), while qualitative data were based on written critical incidents. The analysis compared supervised with unsupervised nurses. The critical incident analysis revealed that supervised nurses continued to use informal support networks as well as their supervision sessions to discuss clinical issues. The MBI found no significant differences in the level of burnout between supervised and unsupervised nurses. However, the NICQ detected some statistically significant differences, with supervised nurses reporting a more listening and supportive management, coping better at work, and feeling that they had better access to support than unsupervised nurses. Closer analysis found that this positive finding was particularly strong among the more junior supervised nurses. The authors conclude from these findings that, where resources are limited, it is better to concentrate on providing clinical supervision to more junior grades of nurses as a valued form of support during their early years as qualified practitioners.

    Ragins BR, Cotton JL, Miller JS. Marginal mentoring: the effects of type of mentor, quality of relationship, and program design on work and career attitudes. Acad Manage J 2000;43(6).

    Abstract reproduced from original.

    Employing a national sample of 1162 employees, the relationship between job and career attitudes and the presence of a mentor, the mentor's type (formal or informal), the quality of the mentoring relationship, and the perceived effectiveness and design of a formal mentoring program is examined. Satisfaction with a mentoring relationship had a stronger impact on attitudes than the presence of a mentor, whether the relationship was formal or informal, or the design of a formal mentoring program.

    E-health and information management

    Health informatics is a subject whose time always seems to be just about to come. In the UK there has been an extraordinary inertia in incorporating the undoubted advantages of electronic support systems into the NHS. Institution of unsuitable or limited systems and unresolved concerns about data security have limited development. E-health may be about to transform the delivery of health care in the USA. Research into measurement of the maturity of information management and technology in the UK NHS is timely, but the NHS needs to work hard to close the e-gap between e-potential and e-reality.

    Fried BM, Weinreich G, Cavalier GM, et al. E-health: technologic revolution meets regulatory constraint. Health Aff 2000;19:124–31.

    Abstract reproduced from original.

    The information technology revolution, exemplified by the expansion of the Internet, promises to shift the US health care system away from the traditional health care delivery model. Profound changes in the business, clinical, and relationship aspects of health care are already occurring. New models for financing and insuring health care, built on mass customization made possible by health information technology (HIT), are transforming relations among employers, employees, and providers. Heavy-handed regulation will constrain the evolution of the HIT-driven health system, limiting its ability to deliver extraordinary clinical achievements, economic efficiencies, and consumer empowerment. The e-health industry must navigate this maze of traditional and new regulations before it can realise its potential in terms of both economics and quality. Some of the regulatory challenges and issues facing the e-health industry are highlighted.

    Starr P. Health care reform and the new economy. Health Aff 2000;19:23–32.

    Abstract reproduced from original.

    The objectives and assumptions of health care reform have changed repeatedly during the past century and may now be entering a new historical phase as a result of the new economy rooted in information technology. In a high growth context, proponents of reform may no longer feel obliged to bundle expanded coverage with tighter cost containment. At the same time, the new digital environment may facilitate innovations intended to inform and expand consumer choice and to improve quality. The new environment elevates transparency to a guiding principle. Health informatics has long been peripheral to reform and must now become more central.

    Finlay PN, Marples CG. A research instrument for the measurement of information management and technology maturity in the UK National Health Service. J Appl Manage Studies 2000;9:197–215.

    Abstract reproduced from original.

    The IMAGINE programme in the UK's National Health Service was designed to raise the quality of information management and technology (IM&T) strategic thinking among participating units in what was the Trent Health Region. The national Facilitated Approach to Information Management (FAIM) initiative followed, with the intent of guiding the management team of individual NHS units in their development of the IM&T strategy. This study describes a research instrument that was developed in IMAGINE and used in FAIM to determine a unit's maturity in IM&T and IM&T strategic thinking.

    Tom Smith

    Research Assistant, Judge Institute Of Management Studies, Cambridge University, Cambridge CB2 1AG, UK

    Gill Harvey

    Research Officer, RCN Institute Of Nursing, Radcliffe Infirmary, Oxford OX2 6HE, UK

    Michael Maresh

    Consultant Obstetrician/Gynaecologist, Royal College Of Obstetricians & Gynaecologists Clinical Audit Unit, St Mary's Hospital, Manchester M13 0JH, UK

    Hugh Mckenna

    University Of Ulster At Coleraine, Coleraine, Co Londonderry, Northern Ireland BT52 1SA, UK

    Richard Baker

    Clinical Governance Research & Development Unit, Department Of General Practice & Primary Health Care, University Of Leicester, Leicester General Hospital, Leicester LE5 4PW, UK

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