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Waring J, Marshall F, Bishop S, et al. An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge. Southampton (UK): NIHR Journals Library; 2014 Sep. (Health Services and Delivery Research, No. 2.29.)

Cover of An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge

An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge.

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Chapter 2Hospital discharge and patient safety: reviews of the literature

Introduction

This chapter reviews the two literatures that inform this study. The first addresses the safety challenge of hospital discharge, elaborating this as a problem of co-ordination and collaboration among various health and social care agencies. Attention is given to major policy changes and interventions aimed at enhancing discharge, as well as research evidence on clinical risk and patient safety. The second literature develops the analysis of patient safety as applied to hospital discharge, suggesting that the transition from acute hospital to community care might be interpreted as a complex system with vulnerable connections between multiple actors. The chapter draws together these literatures to explore how knowledge sharing might be a source of system safety through helping to co-ordinate and integrate the activities of different agencies and, in turn, reducing system complexity.

Understanding hospital discharge

Locating hospital discharge

Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other primary, community or domestic environments. Reflecting this, hospital discharge is not an end point, but rather one of multiple transitions within the patient’s care journey.14,48 The organisation and provision of this transitional care typically involves multiple health and social care actors, who need to co-ordinate their specialist activities so that patients receive integrated and, importantly, safe care. The inherent complexity of co-ordinating a large number of actors, often based in distinct organisations, leads to the view that hospital discharge can be a vulnerable, time-dependent and high-risk episode in the patient pathway.

A prominent example of this complexity is ‘delayed discharge’, where the patient remains in hospital because of the failure to appropriately co-ordinate care between agencies.27,48 According to Victor et al.,49 nearly 30% of older people experience some delay in their hospital discharge, which is known to expose patients to additional hospital-related risks, create emotional and physical dependency, incur additional hospital costs and restrict the availability of inpatient beds. In parallel, premature discharge or discharge without appropriate arrangements for onward care can also lead to complications for patient recovery. For example, the 28-day readmission rate for older people has doubled from 103,000 in 2001–2 to 201,000 in 2010–11,50,51 suggesting that more needs to be done to support patient recovery following acute care.

The problems of delayed or poorly planned discharge illustrate the broader challenge of integrating health and social care.27 Analysing the causes of these delays, Tierney et al.31 point to a range of common factors, including (a) poor communication between health and social care; (b) lack of assessment and planning for discharge; (c) inadequate notice of discharge; (d) inadequate involvement of patient and family; (e) over-reliance on informal care; and (f) lack of attention to the special needs of vulnerable groups. Reflecting this and other evidence,27 policies have repeatedly sought to improve discharge planning, especially the integration of health and social care agencies. A review of these initiatives is outlined below.

Discharge planning

Improved ‘discharge planning’ has been a consistent recommendation of policy and research.27,5254 Over the last two decades, the precise form of discharge planning guidelines has varied to reflect wider health and social care reforms, changing economic imperatives and emerging concerns about care quality.5558 Furthermore, they have been developed both locally, by individual care organisations, and nationally, for example by the NHS Institute for Innovation and Improvement, and there is no commonly agreed model. Despite efforts to promote discharge planning, the recent European HANDOVER study found that health-care professions still did not prioritise discharge planning or interagency communication as supporting enhanced discharge.59 In 2010, the Department of Health published its new discharge workbook, Ready to Go? Planning the Discharge and Transfer of Patients from Hospital and Intermediate Care,30 which outlined 10 ‘steps’ to ensuring a timely, safe and patient-centred transition from hospital, including:

  • effective communication with individuals and across settings
  • alignment of services to ensure continuity of care
  • efficient systems and processes to support discharge and care transfer
  • clear clinical discharge management plans
  • early identification of discharge or transfer date
  • identified named lead co-ordinators
  • organisational review and audit
  • 7-days-a-week proactive discharge planning.

Effective discharge planning is usually associated with a number of common activities and procedures along the care pathway:14,30

  • On admission Prepare detailed and accurate patient record; review assessment information and estimate date of discharge with reference to standard care pathway and complexity of patient circumstances.
  • During admission Undertake regular multidisciplinary assessment of patient condition to identify and assess opportunity for discharge; discuss with patient and family ongoing and continuing needs.
  • At least 48 hours prior to discharge Inform MDT about estimated date of discharge and review assessment criteria; initiate referrals to community health-care providers and social care agencies; contact agencies responsible for ordering and/or installing patient equipment or home modification; social work/care assessment and referrals; complete referral for social care; finalise care package; order take-home medicines; arrange transport.
  • Day of discharge Contact family and carers to confirm follow-up care arrangements; check documentation completion; issue discharge letter to general practitioner (GP); reinforce patient behaviour recommendations and rehabilitation; confirm and finalise transport.
  • Follow-up care Initiate social care package and continuing health-care package, where relevant in consultation with GP.

As these policies suggest, a number of specialist roles and activities are promoted as supporting the integration of different agencies. A longstanding objective has been to promote the use of MDTs in discharge planning.14,53 These are normally organised as formal, usually weekly, meetings between relevant health and social care specialists with the aim of supporting timely communication, inclusive decision-making and continuity of care. Research often describes MDTs as comprising a core team including the named doctor and nurse, occupational therapists (OTs) and physiotherapists (PTs), and representatives from community and social care agencies, as well as family representatives, GPs and other specialist therapists. According to Bull and Roberts,52 MDTs help break down barriers between professional groups and foster a sense of common purpose and trust. Importantly, MDTs provide an opportunity for communication, first between professionals, second with patient and family, and third with community health-care providers. Furthermore, MDTs can help make clear the lines of responsibility for different tasks and create opportunities for individuals to take the lead in co-ordinating the planning process. In practice, however, convening all representatives for individual patients can be challenging in terms of time or resources.27

A further initiative has been the introduction of discharge co-ordinators.14,30 These are individuals, usually experienced nurses, who take lead responsibility for both strategic planning and co-ordination of discharge at the interorganisational level.60 Research suggests that discharge co-ordinators can improve hospital discharge through supporting the integration of different professionals, overseeing and directing planning and addressing emergent problems in a more responsive way.61 In particular, co-ordinators acquire both deeper understanding of and extended relationships with a wider range of care agencies that help them better navigate and align divergent ways of working that usually delay or undermine discharge.52,61,62

Integrating care services

In line with the developments in discharge planning, policies have also introduced new or extended statutory powers, financial opportunities and penalties to support more integrated discharge pathways. For example, the Health Act 199963 enabled health and social care agencies to pool resources to codeliver rehabilitation services. Similarly, in 2005, delayed discharge grants were made available to social service authorities across England to develop reablement services. In contrast, the Community Care (Delayed Discharges) Act (CCDDA) 200364 addressed the problems of integration by allowing hospitals to claim financial reimbursements from local authorities where they delayed discharge by not providing timely services. Against this backdrop, a variety of integrated services and new care pathways have emerged to support the transition from hospital to community, but in doing so have extended (and made more complicated) the range of services involved in discharge planning.

One significant development has been the introduction of ESD. ESD is often associated with the care and rehabilitation of mild-to-moderate stroke patients. It enables patients to return home early with a dedicated package of rehabilitation and reablement of a similar intensity to that provided by inpatient care. ESD is shown to reduce the burden on acute providers and support patient recovery.65 The funding of ESD through joint commissioning between the acute NHS providers, GPs, social services and central government highlights the role of joint working and resource pooling, but there remain variations across the UK, especially in rural areas, where a lack of funding can limit provision.66,67

Intermediate services provide transitional, ‘step-down’ care between acute hospital and the domestic environment (usually for 30 days). Patients are typically declared as ‘medically fit’ but requiring ongoing care or rehabilitation, for example those at risk of readmission or with complex care needs. Rather than receiving rehabilitation at home or in hospital, intermediate care offers a form of residential, hospital-like care, but with a focus on rehabilitation. Research suggests that intermediate care services have been effective in both reducing financial costs and improving patient outcomes.68 Owing to their close proximity to patients’ homes and relatives, community (NHS) hospitals or nursing homes are often used for intermediate and post-discharge rehabilitation. Stays in such units can be longer than in other intermediate care services, yet research suggests patient outcomes are generally favourable.69 The recent Cochrane reviews of long-term rehabilitation in care homes show no evidence of negative health outcomes.65,70

A similar initiative is the introduction of reablement services. These usually involve a dedicated package of social care to support daily living in the immediate period following discharge (e.g. personal care, cooking and cleaning). They are usually managed and provided by local authority social services, although in some cases they are funded through both health and social care budgets. In 2012, the Department of Health allocated £150M for reablement linked to hospital discharge,30 to be allocated through primary care commissioners working in partnership with social care authorities. Significantly, these services are normally arranged and provided by social services to ease transition from hospital for a period of 4–6 weeks, with the expectation that ongoing social care will be reassessed and provided by other agencies.

A further example of service innovation, with particular reference to end-of-life care, is the introduction of ‘fast-track’ discharges. This normally relates to supporting early discharges from hospital for those patients wishing to spend the last days of life in the community with palliative support. This end-of-life discharge can exemplify effective joint working and rapid prioritisation, whereby the patient can be discharged within 48 hours with all specialist support and medications in place.71 For example, funding decisions are established post discharge to remove delays; the needs of the patient and family are met by deliberate use of a continuous dialogue with one specialist co-ordinator; and the emphasis is on timely collaborative working to ensure the patient gets home as requested.72

The threats to ‘safe discharge’

Multiple sources of evidence suggest that care quality can be suboptimal in, or as a consequence of, hospital discharge.28 In a major telephone survey of 400 patients following discharge, Forster et al.17 found that nearly 20% reported some form of adverse event, of which 6% were preventable and 6% ameliorable. Research highlights a number of common discharge-related risks associated, for example, with the management of medicines, the provision of appropriate health and social care, incomplete tests and scans, the fitting and use of home adaptation, and the risks of falls, infections or sores.1728 The underlying sources of these risks can range from factors related to the patient’s condition or comorbidities, to the assessment of patient need, the availability of specialist resources in the community, and wider organisational and cultural factors. For example, research shows that the patient’s condition, such as hip fracture, and other comorbidities, especially cognitive function and fragility, can represent a cluster of risks, particularly for older patients, that can complicate the discharge process.73,74 Research also suggests that time of day, week or year can also have an impact on discharge planning and quality. In particular, discharges during the weekend have been shown to increase the likelihood of death compared with those taking place between Tuesday and Friday, accounting for 34% of all post-discharge deaths.75,76

Although studies highlight the importance of clinical risk in discharge planning, it is not always clear how ‘risk’ is measured. Moreover, the causal analysis of risk is often implicit or an emergent feature of wider trial research. Reviewing the recent literature (Table 1), a number of risks (direct threats to safety) and identified causes (suggested or inferred) are catalogued.

TABLE 1

TABLE 1

Summary of recent research on risks associated with hospital discharge

Although the sources of these risks can be complex and variable, research frequently highlights incomplete, inaccurate and inaccessible information as undermining collaborative workings and contributing to unsafe patient discharge.2729,86,87 A systematic review conducted by Kripalani et al.29 found that communication between hospital and family doctor was often partial or missing, relying primarily upon discharge summaries which were often incomplete, lacking in detail and not provided in a timely manner. Similarly, poor communication between the hospital and social care providers is a long-standing risk factor in adverse events.27,29,88 There remains little extensive research, however, examining the causes of poor communication and adverse events.29,89 Less is known about how communication breakdowns and patient safety are experienced by patients and carers.54 A number of studies propose, and in some cases evaluate, interventions to support communication and information transfer at discharge, including structured communication tools, discharge planning guides, discharge checklists, medicine reconciliation guides and patient education strategies.84,9094 These suggest that effective discharge planning depends upon effective communication and collaboration between health and social care agencies.28,86,95 In his analysis of the factors that support or hinder such communication and collaboration, Glasby27 highlights three dimensions:

  • occupational factors related to the particular knowledge, cultures and practices of different professionals
  • organisational factors related to the working patterns, capabilities and resources of different agencies
  • compatibility and co-ordinating factors related to how occupational and organisational factors are aligned, or differences reconciled.

Attention to these and other factors is needed to better understand and enhance communication and collaboration in discharge planning and care transition. Furthermore, greater appreciation is needed of how communication might undermine not only co-ordination but, in turn, safety. In this sense, communication might be seen as a latent (or active) factor that influences the safety of hospital discharge. The next section develops this idea through relevant theory and research on organisational complexity and safety.

Understanding discharge safety

The quality and safety of hospital discharge is framed by a variety of contextual and system-level factors related to the type of discharge, the configuration of different providers, the availability of resources and, importantly, the relationships between actors in terms of communication, decision-making and joint planning. These issues, as identified in the research literature,2729,86,87 represent possible upstream sources of risk, for example where the failure to communicate and jointly plan services can lead to reduced integration of care agencies and substandard patient care. To better understand this, the present chapter considers relevant patient safety literatures.

The systems approach to patient safety

Current thinking in patient safety is largely informed by theories and research within the fields of ergonomics and human factors. In broad terms, this suggests that performance mistakes are not necessarily brought about by individual negligence, malice or incompetence, but more often by pressures located within the work environment.96 This line of reasoning makes the distinction between ‘active’ and ‘latent’ errors. The former refers to individual slips, mistakes or omissions that lead to patient harm; the latter to the unsafe conditions that create, enable or exacerbate the potential for active error or patient harm. This can include poorly designed working arrangements, poor defence and early-warning mechanisms or an over-reliance on automation. This approach suggests that risk reduction should attend, not to individual performance alone, but to the upstream factors that make performance error prone, for example by standardising task design, improving team cohesion and communication, alleviating situational ambiguity and recognising the influence of resource management and culture.96

This ‘systems approach’ to patient safety has been articulated through policies such as To Err is Human1 and An Organisation with a Memory,2 and developed through major programmes of applied health research.3 For example, it has been used to highlight how a range of ‘task’, ‘team’, ‘situational’ and ‘organisational’ factors contribute to front-line clinical safety.97 Of specific relevance to this study, this conceptualisation of safety draws attention to the way health care is organised and delivered through a system of interdependent elements interacting to achieve a common goal.1 Based upon these ideas, various strategies have been promoted to better understand and address the threats to patient safety. These include, for example, the use of incident reporting procedures to enable clinicians to share their experiences of clinical risk and engender system-wide learning of the root causes;98,99 the creation of a safety culture that is mindful of danger, blame free and responsive to organisational learning;100 and a variety of safety-enhancing interventions, such as ICTs or single-use devices which limit unsafe behaviour; checklists, guidelines and the standardisation of practices to reduce variability; and staff training and culture change activities.3 The ‘human factors’ approach provides a framework (drawing on Vincent101) for conceptualising and investigating the threats to safe discharge (Table 2).

TABLE 2

TABLE 2

Elaborated dimensions of upstream factors

Extending the systems approach

Despite the enormous advances in patient safety research, it has been suggested that the distinctive sociocultural and political dimensions of health care are sometimes overlooked.6 A related view suggests that the human factors approach tends to, although does not always, focus on what might be considered the ‘clinical micro-system’ or local work environment. Take, for example, the emphasis on team skills, communication aids, decision-support tools and checklists. This approach considers less frequently (and in less detail) the wider cultural, institutional or system factors related to workplace practice. Similarly, research has tended to focus within clinical specialities, departments or units, such as operating theatres, care homes or emergency departments, with less attention to the interconnections between these areas and the wider organisation.3 Although organisational and societal factors are recognised,96,101 they are not well developed theoretically or empirically as distinct and interconnected levels of analysis.

Attention to the sources of risk and safety between care settings and processes is important for hospital discharge as relates directly to broader organisational and interorganisational factors. It calls for attention to the nature of the relationships and interdependencies between care organisations as patients pass from hospital to community care. These interdependencies constitute ‘system-level’ (latent) sources of safety, and where research does attend to these interdependencies it shows that the organisation of health care is often so complex and non-linear that the idea of creating a reliable, standardised and safe system remains a ‘wicked problem’.102106 Extending this line of thinking, Hollnagel107 suggests that although the human factors approach goes beyond a simple (single agent) model of error causation to identify instead environmental causation, it too often neglects the non-linear and more complex dynamic coupling involved in many organisational or system processes.

Developing this perspective, a ‘system’ describes a collection of actors, units or parts that together, and through their various connections, form the basis of a structured and relatively bounded entity. Through combining these constituent elements, systems produce particular effects; in many instances these are positive, but they can also be unpredictable, unanticipated or unsafe.108 Broadly speaking, ‘complex systems’ have emergent properties that result from the non-linear or complex connections between their heterogeneous units, subsystems, variables or actors.108,109 Furthermore, complex systems can produce effects that are not always evident from the actions or attributes of the individual parts, owing to the potential for the actions of one component to transform the contexts and actions of others.108 More than this, complex systems are characterised by the absence of structural design and by patterns of self-organising and adaption. For example, the constituent parts within a system interact according to local rules (e.g. customs or cultures) without any overarching direction or control (e.g. leader).110

Health-care systems are increasingly identified as complex systems.102,111114 The organisation and delivery of health care typically involves a vast number of agencies that span different economic sectors (public, private, voluntary), health domains (primary, secondary, tertiary) and care domains (health, social, personal), with distinct roles and responsibilities (commissioners, providers, regulators) and caring specialities. Moreover, the interactions between these actors are not always well defined, but remain dynamic, non-linear and multifaceted, from micro-level clinical interactions, to the meso-level interactions of service planning or commissioning and the macro-level interactions of policy-making and professional associations. As such, health-care systems can change in ways that are not always easily anticipated by policy-makers or service leaders. Extending this line of thinking, hospital discharge might have been conceived as a complex system involving a network of diverse, often heterogeneous actors, interacting in dynamic and non-linear ways that over time produce unpredictable and unanticipated behaviours or outcomes, both positive and negative.

One seminal analysis of organisational complexity that specifically demonstrates the potential for negative consequences is Charles Perrow’s study of Normal Accidents.8 This was developed through an investigation of the system failures that contributed to the Three Mile Island nuclear disaster. His analysis suggests that organisational accidents might be interpreted as inevitable for complex organisational systems, not simply because of the high-risk nature of the work or potential for ‘operator error’, but because of the way organisational processes are configured. In particular, his research elaborates how relatively small, isolated or ‘discrete failures’ that occur in one part of a complex system can cascade and escalate into more substantial disasters. In other words, risks do not develop through linear causal chains but through unpredictable interactions. Where organisational activities are ‘tightly coupled’ there are higher levels of interdependence between work processes, meaning that what happens in one area is influenced by, or influences, the work of others. In health care, research has demonstrated how errors and failures from one department have consequences in other tightly coupled activities across the health-care system.106,115

Although health policies call for greater attention to, and learning about, the systemic threats to patient safety,2 research has largely centred on the latent threats located within discrete and often localised parts of the health-care system.3 There remains limited understanding or evidence of the threats to, and opportunities for, patient safety located within the wider health-care system, especially in the complex interdependencies and non-linear interactions that exist between care providers located in diverse occupational, organisational and sectoral domains.

Applying these ideas to the problem of hospital discharge, it becomes apparent that the complex interdependencies and non-linear couplings between health and social care agencies can be the latent source of poorly timed, inappropriate or unsafe transition from hospital to community care. Policies to support integrated discharge planning have repeatedly looked to introduce improved or more stable couplings between these agencies through, for example, resource pooling and MDTs, and more routine and robust methods of information sharing.30 There remain, however, enduring compatibility factors27 that inhibit co-ordination, and hence discharge safety, given the persistence of heterogeneous, tightly coupled and interdependent working practices.

Integration and safety through knowledge sharing

The above literatures show that hospital discharge is a vulnerable or unsafe stage in the care pathway, often because of the challenges of co-ordinating different health and social care agencies. Extending this idea, this study suggests that hospital discharge might be thought of as a complex system, whereby interdependencies and couplings between caring professionals and agencies can be a source of and threat to patient safety, depending on how they are co-ordinated. The literature repeatedly emphasises communication as helping to reduce this complexity and support co-ordination, for example, in discharge planning or the use of checklists.2729,86,87,94 Extending this idea, we propose the concept of knowledge sharing as a way of supporting the co-ordination and integration of health and social care agencies and mitigating the uncertainties inherent within complex health-care systems.

Knowledge sharing involves more than the communication of information, but instead denotes the exchange and use of meanings, assumptions, practices and know-how between different groups to engender shared understandings and collaborative practices.11 For many improvement strategies, such as knowledge management and evidence-based medicine, knowledge is conceived as an explicit, abstract and tangible resource that can be accessed, codified and exchanged, for example in the form of formal policies or incident reports. In other words, it is an explicit ‘thing’ to be shared with others in the form of documents or evidence. This contrasts with the idea that knowledge or know-how is often tacit, experiential and situated in practice.116 In this sense, knowledge is difficult to share and is typically acquired and developed through participation in communities of practice.117 In short, knowledge is not a ‘thing’ that a community ‘has’, but rather it is what they ‘do’ and who they ‘are’.117 This distinction is important because efforts to understand and indeed promote knowledge sharing should not only focus on the formal assemblages of knowledge, but also the more informal and unarticulated manifestations of know-how. Knowledge sharing is therefore more than the communication of information; it refers to how the meanings, ‘know-how’ and practices of one group or organisation can be shared and integrated into the practices of another.10

The research literature highlights a range of factors that facilitate or inhibit knowledge sharing.1012,118 This includes the characteristics of both ‘donor’ and ‘recipient’ actors, such as their motivations, accessibility, levels of trust, values, hierarchies and absorptive capacity.119121 For example, competitive pressures can inhibit knowledge sharing where it threatens competitive advantage.11 The ‘structural configuration’ of relationships can also channel knowledge flows through ‘central actors’ or knowledge brokers, rather than between peripheral actors.122 Similarly, power hierarchies and cultural difference between actors can have an impact on knowledge sharing, especially where powerful actors assume control of knowledge to advance their own interests.12,123 For professional work, these issues are exacerbated where expert knowledge is closely linked to sociolegal jurisdiction within the division of labour.124 In this context, knowledge sharing can threaten professional boundaries and identities.13,125 The research literature highlights a number of key dimensions that shape the potential for knowledge sharing.117,122,126128 Drawing together this literature, three inter-related factors are identified as shaping knowledge sharing and collaboration within and between health-care organisations:

  • Knowledge Related to differences in epistemology, cognition and sense-making, for example how actors make sense of discharge; the types of knowledge that guide practice; and whether or not knowledge represents a competitive resource.
  • Culture Related to the shared norms, attitudes and values that guide practices, for example when knowledge should be shared and with whom; how identities and trust reinforce knowledge hoarding; the different philosophies of care that guide work organisation.
  • Organisation Related to the influence of (inter/intra)organisational structures, processes, regulatory factors and management priorities that shape knowledge sharing, such as sociolegal rules, professional jurisdictions, organisational connections and resource constraints.

Knowledge sharing for safe discharge

Applying the above literatures to hospital discharge, this study investigates how patterns of knowledge sharing among health and social care agencies influence discharge planning and care transition. Developing this view, knowledge sharing is conceptualised as a latent source of safety that, through shaping the patterns of co-ordination, shared decision-making and integrated working, can mitigate system complexity. As such, understanding the barriers to and drivers of knowledge sharing can contribute to the development of new knowledge on the possibilities for improved integration and safety in hospital discharge. These lines of analysis are tentatively outlined in Table 3.

TABLE 3

TABLE 3

Application of framework to hospital discharge

Summary

This chapter has reviewed research literatures on hospital discharge and patient safety to suggest that discharge from hospital to community is located within a complex and vulnerable system, involving a diverse range of heterogeneous actors interacting in dynamic and non-linear ways. Policy and research highlight the need for improved integration, especially in discharge planning and care transition; however, given the complex, dynamic patterns of interaction and the variable institutional environments in which caring professionals work, this integration remains problematic. The idea of communication and collaborative decision-making is frequently cited as a basis for integration.2729,86,87 The study extends this idea by suggesting that knowledge sharing can support enhanced integration and collaboration among system actors, based upon the exchange and alignment of different meanings, assumptions and know-how, as well as more explicit knowledge and information. Knowledge sharing is therefore presented as a source of (and threat to) safety within the complex systems involved in hospital discharge, and requires further empirical understanding.

Copyright © Queen’s Printer and Controller of HMSO 2014. This work was produced by Waring et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK259995

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