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III Science, technology and research
IV Health and social care
V Reproduction and making families
VI Widening the scope of feminist bioethics
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Ethics involves examining values and identifying what is good, right, and justified - and why. Diverse values and ethical issues run through healthcare improvement, but they are not always recognised or given the attention they need. While much effort goes into understanding whether intervention X effectively leads to change Y, questions such as 'is X ethically acceptable?', 'does Y count as an improvement?', 'should Y be prioritised?', and 'if so, why?' are sometimes neglected. This Element demonstrates the ethical considerations and rich array of values that inevitably underpin both the goals of healthcare improvement (what aspects of quality or what kinds of good are pursued) and how improvement work is undertaken. It outlines an agenda for improvement ethics with the aim of helping those involved in healthcare improvement to reflect on and discuss ethical aspects of their work more explicitly and rigorously. This title is also available as Open Access on Cambridge Core.

© 2019 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd. ; Peer reviewed ; Publisher PDF

Abstract Background A survey was carried out in the Grampian region of Scotland with a random sample of 10,000 adults registered with a General Practitioner in Grampian. The study complied with new legislation requiring a two-stage approach to identify and recruit participants, and examined the implications of this for response rates, non-response bias and speed of response. Methods A two-stage survey was carried out consistent with new confidentiality guidelines. Individuals were contacted by post and asked by the Director of Public Health to consent to receive a postal or electronic questionnaire about communicating their views to the NHS. Those who consented were then sent questionnaires. Response rates at both stages were measured. Results 25% of people returned signed consent forms and were invited to complete questionnaires. Respondents at the consent stage were more likely to be female (odds ratio (OR) response rate of women compared to men = 1.5, 95% CI 1.4, 1.7), less likely to live in deprived postal areas (OR = 0.59, 95% CI 0.45, 0.78) and more likely to be older (OR for people born in 1930–39 compared to people born in 1970–79 = 2.82, 95% CI 2.36, 3.37). 80% of people who were invited to complete questionnaires returned them. Response rates were higher among older age groups. The overall response rate to the survey was 20%, relative to the original number approached for consent (1951/10000). Conclusion The requirement of a separate, prior consent stage may significantly reduce overall survey response rates and necessitate the use of substantially larger initial samples for population surveys. It may also exacerbate non-response bias with respect to demographic variables.

Funding: KG was supported by an MRC Methodology Research Fellowship (MR/L01193X/1). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the MRC. PRW was funded by the MRC North West Hub for Trials Methodology Research (MR/K025635/1) and the MRC/NIHR Trials Methodology Research Partnership (MR/S014357/1). The Health Services Research Unit is core-funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates (CZU/3/3). Acknowledgements: The ELICIT Study team would like to thank Cynthia Fraser for help with developing and running the search strategies for the literature review, the DelphiManager team for all their support and guidance on the use of the Delphi platform, Health Services Research Unit Patient Involvement Group critical review of the Delphi questionnaire before dissemination, Heather Bagley for further comments on the Delphi questionnaire and also for dissemination of the survey information and link to a range of patient facing organisations, and to Beverley Smith for her assistance in organising the consensus meeting. We would also like to thank all participants of the study (including interview participants, Delphi respondents, and consensus meeting members) and organisations who disseminated the survey. Data Sharing: Data from the systematic review and Delphi survey phases of work are available from the corresponding author on request. ; Peer reviewed ; Publisher PDF

Funding RECAP was funded by the Academy of Medical Sciences (SBF002\1014) and KG was funded by a Medical Research Council Strategic Skills Methodology Fellowship (MR/L01193X/1). The Health Services Research Unit, Institute of Applied Health Sciences (University of Aberdeen), is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates (CZU/3/3). ; Peer reviewed ; Publisher PDF

Acknowledgements Many thanks to Cynthia Fraser, Information Specialist (Health Services Research Unit, University of Aberdeen), for leading the design and conduct of the literature searches, document retrieval and reference management. The Health Services Research Unit, University of Aberdeen is core funded by the Chief Scientist Office of the Scottish Government's Health and Social Care Directorates. The authors accept full responsibility for this paper. Funding This research was funded by The Health Foundation (Project reference 7209). ; Peer reviewed ; Publisher PDF

AbstractBackground: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK‐wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy.Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients.Methods: at the macro‐level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced.Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients.Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.

Objective: To elicit informed views from Australian women aged 70–74 regarding the acceptability of ceasing to invite women their age to participate in government-funded mammography screening (BreastScreen). Design: Two community juries held in 2017. Setting: Greater Sydney, a metropolis of 4.5 million people in New South Wales, Australia. Participants: 34 women aged 70–74 with no personal history of breast cancer, recruited by random digit dialling and previously randomly recruited list-based samples.

Objective To elicit informed views from Australian women aged 70-74 regarding the acceptability of ceasing to invite women their age to participate in government-funded mammography screening (BreastScreen). Design Two community juries held in 2017. Setting Greater Sydney, a metropolis of 4.5 million people in New South Wales, Australia. Participants 34 women aged 70-74 with no personal history of breast cancer, recruited by random digit dialling and previously randomly recruited list-based samples. Main outcomes and measures Jury verdict and rationale in response to structured questions. We transcribed audio-recorded jury proceedings and identified central reasons for the jury's decision. Results The women's average age was 71.5 years. Participants were of diverse sociocultural backgrounds, with the sample designed to include women of lower levels of educational attainment. Both juries concluded by majority verdict (16-2 and 10-6) that BreastScreen should continue to send invitations and promote screening to their age group. Reasons given for the majority position include: (1) sending the invitations shows that society still cares about older women, empowers them to access preventive health services and recognises increasing and varied life expectancy; (2) screening provides women with information that enables choice and (3) if experts cannot agree, the conservative approach is to maintain the status quo until the evidence is clear. Reasons for the minority position were the potential for harms through overdiagnosis and misallocation of scarce health resources. Conclusions Preventive programmes such as mammography screening are likely to have significant symbolic value once they are socially embedded. Arguments for programme de-implementation emphasising declining benefit because of limited life expectancy and the risks of overdiagnosis seem unlikely to resonate with healthy older women. In situations where there is no consensus among experts on the value of established screening programmes, people may strongly ...

RECAP was funded by the Academy of Medical Sciences (SBF002\1014), and KG was funded by the Medical Research Council (MR/L01193X/1). AS was funded by the Medical Research Council (grant number: MC_UU_12023/24). The Health Services Research Unit is core-funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates (CZU/3/3). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the funders. ; Peer reviewed ; Publisher PDF