Making Ends Meet: A Conceptual and Ethical Analysis of Efficiency.

Efficiency is often overlooked as an ethical value and seen as ethically relevant chiefly when it conflicts with other values, such as equality. This article argues that efficiency is a rich and philosophically interesting concept deserving of independent normative examination. Drawing on a detailed healthcare case study, we argue that making assessments of efficiency involves value-laden, deliberative judgments about how to characterize the functioning of human systems.

Telephone consulting for 'Personalised Care and Support Planning' with people with long-term conditions: a qualitative study of healthcare professionals' experiences during COVID-19 restrictions and beyond.

Background: Personalised Care and Support Planning (PCSP) replaces conventional annual reviews for people with long-term conditions. It is designed to help healthcare professionals (HCPs) and patients engage in conversations as equals and collaboratively plan actions oriented to each patient's priorities, alongside biomedical concerns. Little is known about how the shift to remote consulting initiated with COVID-19 restrictions has impacted PCSP.

Truth and consequences.

In his 1987 paper "Truth or Consequences," Dan Brock describes a deep conflict between the goals and virtues of philosophical scholarship and public policymaking: whereas the former is concerned with the search for truth, the latter must primarily be concerned with promoting good consequences. When philosophers are engaged in policymaking, he argues, they must shift their primary goal from truth to consequences-but this has both moral and methodological costs. Brock's argument exemplifies a pessimistic, but not uncommon, view of the possible shape and nature of applied philosophy.

Implementing and evaluating care and support planning: a qualitative study of health professionals' experiences in public polyclinics in Singapore.

Background: Two polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals' perspectives on CSP to inform future developments.

Methods: Qualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators.

A wide vocabulary for person-centred care.

Many different words and phrases are used to describe healthcare that treats patients as people. Do terms such as 'person centred', 'patient centred', 'people centred' and 'personalised' mean broadly the same thing or do they refer to distinct concepts? Should we prefer one over the others? In this essay, we set out the value and limitations of some of the different terms used to describe what we broadly refer to as 'person-centred care'. We offer a critical conceptual analysis of the most commonly used words and phrases in this domain, exploring how they differ from, and relate to, one another.

Tackling disrespect in health care: The relevance of socio-relational equality.

Disrespect in health care often persists despite firm commitments to respectful service provision. This conceptual paper highlights how the ways in which respect and disrespect are characterised can have practical implications for how well disrespect can be tackled. We stress the need to focus explicitly on disrespect (not only respect) and propose that disrespect can usefully be understood as a failure to relate to people as equals.

Varieties of improvement expertise: Knowledge and contestation in health-care improvement.

The 'improvement' of health care is now established and growing as a field of research and practice. This article, based on qualitative data from interviews with 21 senior leaders in this field, analyses the growth of improvement expertise as not simply an expansion but also a multiplication of 'ways of knowing'. It illustrates how health-care improvement is an area where contests about relevant kinds of knowledge, approaches and purposes proliferate and intersect.

Patient Safety and the Question of Dignitary Harms.

Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury to patients, often caused by technical error. However, some contributions to the patient safety literature have argued that disrespectful behavior towards patients can cause harm, even when it does not lead to physical injury.

Unifying and universalizing Personalised Care? An analysis of a national curriculum with implications for policy and education relating to person-centred care.

Objective: To examine the Curriculum of England's Personalised Care Institute as a national initiative to promote person-centred practice.

Method: Analysis of Curriculum content and discourse RESULTS: The Curriculum describes an educational framework which aspires to unify approaches and universalize provision of Personalised Care. It presents 8 "models and approaches" and 6 "components" within the "whole" of Personalised Care.

Vagueness and variety in person-centred care.

Person-centred care is a cornerstone of contemporary health policy, research and practice. However, many researchers and practitioners worry that it lacks a 'clear definition and method of measurement,' and that this creates problems for the implementation of person-centred care and limits understanding of its benefits. In this paper we urge caution about this concern and resist calls for a clear, settled definition and measurement approach.

Implementing shared decision-making in UK: Progress 2017-2022.

Shared decision making has been on the policy agenda in the UK for at least twelve years, but it lacked a comprehensive approach to delivery. That has changed over the past five years, and we can now see significant progress across all aspects of a comprehensive approach, including leadership at policy, professional and patient levels; infrastructure developments, including the provision of training, tools and campaigns; and practice improvements, such as demonstrations, measurement and coordination. All these initiatives were necessary, but the last, central coordination, would appear to be key to success.

What, how, when and who of trial results summaries for trial participants: stakeholder-informed guidance from the RECAP project.

Objective: To generate stakeholder informed evidence to support recommendations for trialists to implement the dissemination of results summaries to participants.

Design: A multiphase mixed-methods triangulation design involving Q-methodology, content analysis, focus groups and a coproduction workshop (the REporting Clinical trial results Appropriately to Participants project).

Setting: Phase III effectiveness trials.

Pushing poverty off limits: quality improvement and the architecture of healthcare values.

Background: Poverty and social deprivation have adverse effects on health outcomes and place a significant burden on healthcare systems. There are some actions that can be taken to tackle them from within healthcare institutions, but clinicians who seek to make frontline services more responsive to the social determinants of health and the social context of people's lives can face a range of ethical challenges. We summarise and consider a case in which clinicians introduced a poverty screening initiative (PSI) into paediatric practice using the discourse and methodology of healthcare quality improvement (QI).

Talking it better: conversations and normative complexity in healthcare improvement.

In this paper, we consider the role of conversations in contributing to healthcare quality improvement. More specifically, we suggest that conversations can be important in responding to what we call 'normative complexity'. As well as reflecting on the value of conversations, the aim is to introduce the dimension of normative complexity as something that requires theoretical and practical attention alongside the more recognised challenges of complex systems, which we label, for short, as 'explanatory complexity'.

Some Unresolved Ethical Challenges in Healthcare Decision-Making: Navigating Family Involvement.

Family involvement in healthcare decision-making for competent patients occurs to varying degrees in many communities around the world. There are different attitudes about who should make treatment decisions, how and why. Legal and professional ethics codes in most jurisdictions reflect and support the idea that competent patients should be enabled to make their own treatment decisions, even if others, including their healthcare professionals, disagree with them.

An international core outcome set for evaluating interventions to improve informed consent to clinical trials: The ELICIT Study.

Objective: To develop a core outcome set for the evaluation of interventions that aim to improve how people make decisions about whether to participate in randomized controlled trials (of healthcare interventions), the ELICIT Study.

Study Design: International mixed-method study involving a systematic review of existing outcomes, semi-structured interviews, an online Delphi survey, and a face-to-face consensus meeting.

Results: The literature review and stakeholder interviews (n = 25) initially identified 1045 reported outcomes that were grouped into 40 individually distinct outcomes.

Made to Measure: The Ethics of Routine Measurement for Healthcare Improvement.

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited-it often produces only modest effects or fails to generate anticipated improvements at all.

Revisiting the equity debate in COVID-19: ICU is no panacea.

Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit (ICU) resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off.

The Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) protocol: a non-randomised controlled trial of personalised care and support planning for persons living with diabetes.

Background: Personalised care and support planning (CSP) has been shown to improve diabetes outcomes, patient experience and provider morale in the care of persons living with diabetes. However, this has not been confirmed in controlled studies. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) is a pragmatic controlled trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in the public primary care setting in Singapore.

Defining What is Good: Pluralism and Healthcare Quality.

'Quality' is a widely invoked concept in healthcare, which broadly captures how good or bad a healthcare service is. While quality has long been thought to be multidimensional, and thus constitutively plural, we suggest that quality is also plural in a further sense, namely that different conceptions of quality are appropriately invoked in different contexts, for different purposes. Conceptual diversity in the definition and specification of quality in healthcare is, we argue, not only inevitable but also valuable.

How should the 'privilege' in therapeutic privilege be conceived when considering the decision-making process for patients with borderline capacity?

Therapeutic privilege (TP) is a defence that may be available to doctors who fail to disclose to the patient relevant information when seeking informed consent for treatment if they have a reasonable belief that providing that information would likely cause the patient concerned serious physical or mental harm. In a landmark judgement, the Singapore Court of Appeal introduced a novel interpretation of TP, identifying circumstances in which it might be used with patients who did not strictly lack capacity but might be inclined to refuse recommended treatments. In this paper, we explore the conceptual and practical challenges of this novel interpretation of TP.

What does 'quality' add? Towards an ethics of healthcare improvement.

In this paper, we argue that there are important ethical questions about healthcare improvement which are underexplored. We start by drawing on two existing literatures: first, the prevailing, primarily governance-oriented, application of ethics to healthcare 'quality improvement' (QI), and second, the application of QI to healthcare ethics. We show that these are insufficient for ethical analysis of healthcare improvement.

Health professionals' experiences and perspectives on food insecurity and long-term conditions: A qualitative investigation.

Estimates suggest that over 10% of the UK population are affected by food insecurity. International evidence indicates that food insecurity is a risk factor for many long-term health conditions, and can adversely affect people's ability to manage existing conditions. Food insecurity is thus not only a serious social concern but also a healthcare issue requiring the attention of UK health professionals.

Risk, Overdiagnosis and Ethical Justifications.

Many healthcare practices expose people to risks of harmful outcomes. However, the major theories of moral philosophy struggle to assess whether, when and why it is ethically justifiable to expose individuals to risks, as opposed to actually harming them. Sven Ove Hansson has proposed an approach to the ethical assessment of risk imposition that encourages attention to factors including questions of justice in the distribution of advantage and risk, people's acceptance or otherwise of risks, and the scope individuals have to influence the practices that generate risk.