Paul Atkinson

Introduction: Antipsychotic medication is increasingly prescribed to patients with serious mental illness. Patients with serious mental illness often have cardiovascular and metabolic comorbidities, and antipsychotics independently increase the risk of cardiometabolic disease. Despite this, many patients prescribed antipsychotics are discharged to primary care without planned psychiatric review. We explore perceptions of healthcare professionals and managers/directors of policy regarding reasons for increasing prevalence and management of antipsychotics in primary care. Methods: Qualitative study using semi-structured interviews with 11 general practitioners (GPs), 8 psychiatrists, and 11 managers/directors of policy in the United Kingdom. Data was analysed using thematic analysis. Results: Respondents reported competency gaps that impaired ability to manage patients prescribed antipsychotic medications, arising from inadequate postgraduate training and professional development. GPs lacked confidence to manage antipsychotic medications alone; psychiatrists lacked skills to address cardiometabolic risks and did not perceive this as their role. Communication barriers, lack of integrated care records, limited psychology provision, lowered expectation towards patients with serious mental illness by professionals, and pressure to discharge from hospital resulted in patients in primary care becoming ‘trapped’ on antipsychotics, inhibiting opportunities to deprescribe. Organisational and contractual barriers between services exacerbate this risk, with socioeconomic deprivation and lack of access to non-pharmacological interventions driving overprescribing. Professionals voiced fears of censure if a catastrophic event occurred after stopping an antipsychotic. Facilitators to overcome these barriers were suggested. Conclusions: People prescribed antipsychotics experience a fragmented health system and suboptimal care. Several interventions could be taken to improve care for this population, but inadequate availability of non-pharmacological interventions and socioeconomic factors increasing mental distress need policy change to improve outcomes. The role of professionals’ fear of medicolegal or regulatory censure inhibiting antipsychotic deprescribing was a new finding in this study.

Introduction Antipsychotic medication is increasingly prescribed to patients with serious mental illness. Patients with serious mental illness often have cardiovascular and metabolic comorbidities, and antipsychotics independently increase the risk of cardiometabolic disease. Despite this, many patients prescribed antipsychotics are discharged to primary care without planned psychiatric review. We explore perceptions of healthcare professionals and managers/planners of policy regarding management of antipsychotics in primary care. Methods Qualitative study using semi-structured interviews with 11 general practitioners (GPs), 8 psychiatrists, and 11 managers/planners of policy in the United Kingdom. Interviews were studied using inductive thematic analysis. Results Respondents reported competency gaps that impaired ability to manage patients prescribed antipsychotic medications holistically, arising from inadequate postgraduate training and professional development. GPs lacked confidence to manage antipsychotic medications alone; psychiatrists lacked skills to address cardiometabolic risks and did not perceive this as their role. Communication barriers, lack of integrated care records, limited psychology provision, lowered expectation of patients with serious mental illness by professionals, and pressure to discharge from hospital resulted in patients in primary care becoming ‘trapped’ on antipsychotics, inhibiting opportunities to deprescribe. Organisational and contractual barriers between organisations exacerbate this risk, with socioeconomic deprivation and lack of access to non-pharmacological alternatives driving overprescribing. GPs and psychiatrists voiced professional fears of being blamed if an event causing harm occurred after stopping an antipsychotic, which inhibited deprescribing. A range of actions to overcome these barriers were suggested. Conclusions People prescribed antipsychotics experience a fragmented health system and suboptimal care. Many simple steps could be taken to improve quality of care for this population but inadequate availability of non-pharmacological alternatives and socioeconomic factors increasing mental distress need key policy changes to improve the current situation.

We present empirical evidence from anonymized interviews with local leaders on governance challenges facing health and social care in England. Responding to the Covid-19 pandemic has allowed policy practitioners to see the sector’s problems with new clarity and illustrated potential solutions. We draw conclusions about central government policymaking, regional and local policymaking and some specifics of the pandemic response. Even during the Covid-19 pandemic, we found continuity with governance patterns identified in earlier scholarship. Command and control from the center, although understandably prominent as an emergency response, was not the whole story. Network governance was also visible, for instance in the ability of local organizations to shape the design of national policy on community testing. Central government was also persuaded, reluctantly, to share responsibility with subnational policy makers, for example in contact tracing and the use of individual-level health data, when local authorities demonstrated its usefulness and showed ability and responsibility in its management. The stresses of a crisis will always challenge mutual trust between local and central government, but lessons need to be learned. Central government could explain its actions more effectively, be more transparent about acknowledging uncertainty, and avoid promises which run ahead of the possibilities of delivery. We show how, during the Covid-19 pandemic, central government has neglected the potential contribution of local government even more than previously: we go beyond this to suggest practical steps which local government can take despite central resistance, drawing on sound science, insight into local conditions and community engagement.

Background: In 2006, the research and development (R&D) activity of England’s national healthcare system, the National Health Service, was reformed. A National Institute for Health Research (NIHR) was established within the Department of Health, the first body to manage this activity as an integrated system, unlocking significant increases in government funding. This article investigates how the NIHR came to be set up, and why it took the form it did. Our goal was a better understanding of ‘how we got here’.Methods: We conducted oral history interviews with 38 key witnesses, held a witness seminar, and examined published and unpublished documents.Results: We conclude that the most important forces shaping the origin of NIHR were the growing impact of evidence-based medicine on service policies, the growth of New Public Management ways of thinking, economic policies favouring investment in health R&D and buoyant public funding for healthcare. We note the strong two-way interaction between the health research system and the healthcare system — while beneficial for the use of research, challenges for healthcare (such as stop-go funding) could also produce challenges for health research.Conclusions: Understanding how and why England came to have a centralised health service research system alongside a long-established funder of biomedical research (the Medical Research Council) helps us interpret the significance of the English health research experience for other countries and helps English policy-makers better understand their present options.Learning lessons from the features of the English health research system calls for an understanding of the processes which shaped it. Firstly, the publicly funded, nationally organised character of healthcare promoted government interest in evidence-based medicine, made research prioritisation simpler and helped promote the implementation of findings. Secondly, the essential role of leadership by a group who valued research for its health impact ensured that new management methods (such as metrics and competitive tendering) were harnessed to patient benefit, rather than as an end in themselves. A policy window of government willingness to invest in R&D for wider economic goals and buoyant funding of the health system were also effectively exploited.

Corpus linguistics enables the analysis of patterns in large bodies of written material. The use of this approach to trace discourses about infant mortality in all of the text published by four newspapers in England and Wales between 1870 and 1900 detects systematic variations in views about infant welfare by locality. It also reveals some of the strengths and weaknesses inherent in interrogating digitized text with linguistic tools in historical research.