BackgroundProblems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS).MethodsMixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary.ResultsWe found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care.ConclusionsOur results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

Key Points Question How are drug company payments to health care organizations distributed in the UK health care system? Findings This cross-sectional study of the Disclosure UK database found that in 2015, 4028 health care organizations received US $72 110 156.6 from 100 companies. Although financial relationships were spread across the health care system, a few key donors and beneficiaries of industry funding were found. Meaning More policy attention is needed to disclose organizational conflicts of interests, particularly in areas of the health care system with a high concentration of industry payments.

Drug company payment disclosures have limited transparency, but Piotr Ozieranski and colleagues find that they are increasing in value and are targeted at select patient organisations

BackgroundQuality improvement collaboratives (QICs) continue to be widely used, yet evidence for their effectiveness is equivocal. We sought to explain what happened in Stroke 90:10, a QIC designed to improve stroke care in 24 hospitals in the North West of England. Our study drew in part on the literature on collective action and inter-organizational collaboration. This literature has been relatively neglected in evaluations of QICs, even though they are founded on principles of co-operation and sharing.MethodsWe interviewed 32 professionals in hospitals that participated in Stroke 90:10, conducted a focus group with the QIC faculty team, and reviewed purposively sampled documents including reports and newsletters. Analysis was based on a modified form of Framework Analysis, combining sensitizing constructs derived from the literature and new, empirically derived thematic categories.ResultsImprovements in stroke care were attributed to QIC participation by many professionals. They described how the QIC fostered a sense of community and increased attention to stroke care within their organizations. However, participants’ experiences of the QIC varied. Starting positions were different; some organizations were achieving higher levels of performance than others before the QIC began, and some had more pre-existing experience of quality improvement methods. Some participants had more to learn, others more to teach. Some evidence of free-riding was found. Benchmarking improvement was variously experienced as friendly rivalry or as time-consuming and stressful. Participants’ competitive desire to demonstrate success sometimes conflicted with collaborative aims; some experienced competing organizational pressures or saw the QIC as duplication of effort. Experiences of inter-organizational collaboration were influenced by variations in intra-organizational support.ConclusionsCollaboration is not the only mode of behavior likely to occur within a QIC. Our study revealed a mixed picture of collaboration, free-riding and competition. QICs should learn from work on the challenges of collective action; set realistic goals; account for context; ensure sufficient time and resources are made available; and carefully manage the collaborative to mitigate the risks of collaborative inertia and unhelpful competitive or anti-cooperative behaviors. Individual organizations should assess the costs and benefits of collaboration as a means of attaining quality improvement.

ObjectivesTo examine the accessibility and quality of drug company payment data in Europe.DesignComparative policy review of payment data in countries with different regulatory approaches to disclosure.Setting37 European countries.ParticipantsEuropean Federation of Pharmaceutical Industries and Associations, its trade group and their drug company members; eurosfordocs.eu, an independent database integrating payments disclosed by companies and trade groups; regulatory bodies overseeing payment disclosure.Main outcome measuresRegulatory approaches to disclosure (self-regulation, public regulation, combination of the two); data accessibility (format, structure, searchability, customisable summary statistics, downloadability) and quality (spectrum of disclosed characteristics, payment aggregation, inclusion of taxes, recipient or donor identifiers).ResultsOf 30 countries with self-regulation, five had centralised databases, with Disclosure UK displaying the highest accessibility and quality. In 23 of the remaining countries with self-regulation and available data, disclosures were published in the portable document format (PDF) on individual company websites, preventing the public from understanding payment patterns. Eurosfordocs.eu had greater accessibility than any industry-run database, but the match between the value of payments integrated in eurosfordocs.eu and summarised separately by industry in seven countries ranged between 56% and 100% depending on country. Eurosfordocs.eu shared quality shortcomings with the underlying industry data, including ambiguities in identifying payments and their recipients. Public regulation was found in 15 countries, used either alone (3), in combination (4) or in parallel with (8) self-regulation. Of these countries, 13 established centralised databases with widely ranging accessibility and quality, and sharing some shortcomings with the industry-run databases. The French database, Transparence Santé, had the highest accessibility and quality, exceeding that of Disclosure UK.ConclusionsThe accessibility and quality of payment data disclosed in European countries are typically low, hindering investigation of financial conflicts of interest. Some improvements are straightforward but reaching the standards characterising the widely researched US Open Payments database requires major regulatory change.