Cross-border and domestic surrogacy in the UK context: an exploration of practical and legal decision-making.

This study aimed to explore UK intending parent's reasons for cross-border and domestic surrogacy, their preparations for the birth and the practical and legal challenges faced after the birth. An online survey was completed by 203 participants, of which 132 had a child born through surrogacy, 33 were in the process of surrogacy and 38 were planning a surrogacy arrangement. The most common reason for pursuing surrogacy in the UK was wanting a relationship with the surrogate (43%; n = 17) and for conducting surrogacy in the USA was because of a better legal framework (97%; n = 60). Parents returning to the UK from countries other than USA experienced greater delay and difficulties in obtaining the necessary documents for their return. This study highlights the disparities in parents' experiences of undergoing surrogacy in different countries, the frustrations some face in obtaining legal parenthood and the feelings of stress and anxiety this may cause. Whilst this is the first study comparing the experiences of people from the UK having surrogacy in different countries, the representativeness of the sample is unknown. The findings are important in identifying future directions for research, including assessing the impact of these early decisions and experiences for later parental wellbeing and children's welfare.

Parents' relationship with their surrogate in cross-border and domestic surrogacy arrangements: comparisons by sexual orientation and location.

OBJECTIVE: To study heterosexual and gay couples' relationship with their surrogate and their disclosure decisions when the surrogacy arrangement was completed domestically compared with internationally. DESIGN: Cross-sectional study. SETTING: Not applicable. PATIENT(S): Participants were 40 gay couples and 76 heterosexual couples who had domestic surrogacy in the United Kingdom (UK) (n = 38) or international surrogacy in the United States (n = 58) or Asia (20). Most (75%) of the children were aged <4 years. INTERVENTION(S): Online surveys containing open-ended and multiple-choice questions. MAIN OUTCOME MEASURE(S): Experiences of finding a surrogate, relationship with the surrogate, and disclosure to the child were examined among UK parents who had undergone surrogacy in the UK, United States, or India/Thailand. RESULT(S): Parents who had surrogacy in the UK and United States felt very involved in the pregnancy compared with those who had surrogacy in Asia. Couples whose surrogacy was completed in Asia were less likely to want contact with their surrogate after the birth and were also less likely to have any current contact with the surrogate. Parents who had surrogacy in the UK and United States described positive relationships with their surrogate. Gay couples intended to tell their child about surrogacy more than heterosexual couples. CONCLUSION(S): The specific country where couples conducted their surrogacy arrangement (i.e. United States, UK, or Thailand/India) was associated with how involved they were in the pregnancy and their contact with the surrogate over time. Limitations of the study include use of survey methodology and that the representativeness of the sample is not known.

Physical restraint in a therapeutic setting; a necessary evil?

Physical restraint of people experiencing mental health problems is a coercive and traumatic procedure which is only legally permitted if it is proportionate to the risk presented. This study sought to examine the decision-making processes used by mental health staff involved in a series of restraint episodes in an acute care setting. Thirty nurses were interviewed either individually or in focus groups to elicit their views on restraint and experience in specific incidents. Four factors which influenced the decision to restrain were identified: contextual demands; lack of alternatives; the escalatory effects of restraint itself; and perceptions of risk. While some of these factors are amenable to change through improvements in practice, training and organisational culture, nurses viewed restraint as a necessary evil, justified on the basis of the unpredictable nature of mental illness and the environment in which they worked.

Marvelous medicines and dangerous drugs: the representation of prescription medicine in the UK newsprint media.

Using discourse analysis, this study examines the representation of prescription medicines in the UK newsprint media and, specifically, how the meaning and function of medicines are constructed. At the same time, it examines the extent to which the newsprint media represents a resource for health information, and considers how it may encourage or challenge faith in modern medicine and medical authority. As such, it extends analysis around concepts such as the informed patient and examines the representation of patients and doctors and the extent to which patient-doctor identities promoted in the newsprint media reflect a shift away from paternalism to negotiated encounters. Findings show the media constructs a discrete, contradictory, and frequently oversimplified set of characterizations about medicine. Moreover, it discursively constructs realities that justify and sustain medial dominance. Ideological paradigms in discourse assign patients as passive and disempowered while simultaneously privileging "expert" knowledge. This constructs a reality that marginalizes patients' participation in decision-making.

Perceptions of the impact of primary care organizations on GP prescribing: the iron fist in the velvet glove?

PURPOSE: This qualitative study aims to examine key stakeholders' perspectives of primary care group/trust prescribing strategies. Within the context of general practice prescribing, the paper also debates the wider issue of whether GPs' prescribing autonomy is under threat from managerial expansion following recent organisational changes in primary care. DESIGN/METHODOLOGY/APPROACH: Data were obtained from focus groups and a series of individual semi-structured interviews with GPs and key primary care organisation stakeholders. FINDINGS: The data underlie a tension between the managerial objective of cost-restraint and GPs' commitment to quality improvement and individual clinical patient management. In presenting both managerial and medical narratives, two divergent and often conflicting discourses emerge, which leads to speculation that managerial attempts to constrain prescribing autonomy will achieve only limited success. The contention is that GPs' discourse features as a challenge to a managerial discourse that reflects attempts to regulate, standardise and curtail clinical discretion. This is due not only to GPs' expressed hegemonic ideals that clinical practice centres on the interests of the individual patient, but also to the fact that the managerial discourse of evidence-based medicine encapsulates only a limited share of the knowledge that GPs draw on in decision making. However, while managers' discourse presented them as unwilling to impose change or directly challenge clinical practice, evidence also emerged to suggest that is not yet possible to be sufficiently convinced of the future retention of prescribing autonomy. On the other hand, the use of peer scrutiny posed an indirect managerial influence on prescribing, whilst the emergence of prescribing advisors as analysts of cost-effectiveness may threaten doctors' dominance of medical knowledge. RESEARCH LIMITATIONS/IMPLICATIONS: There is a continuing need to analyse the impact of the new managerial reforms on primary care prescribing. ORIGINALITY/VALUE: This study provides a snapshot of managerial and GP relations at a time of primary care transition.

New drug prescribing by hospital doctors: the nature and meaning of knowledge.

In the UK the high cost of new drugs is partly accountable for the growth in spending on prescription drugs. Most prescribing takes place in general practice and the influence of secondary care prescribing on primary care prescribing is well recognized; yet the factors that influence hospital prescribing have been little researched. Drawing on accounts of actual prescribing events from hospital doctors from a range of specialties, we investigated the processes by which new drugs come into practice, from hospital doctors' awareness of new drugs to the assimilation and interpretation of evidential sources. The determinants of new drug prescribing were interconnected within four forms of knowledge: scientific knowledge, social knowledge, patient knowledge and experiential knowledge. Furthermore, the nature of knowledge could only be understood within its situated context. The revelation of multiple and contingent forms of knowledge highlights the problematic nature of knowledge construction within the approaches of evidence-based medicine.

A qualitative study of GPs' and PCO stakeholders' views on the importance and influence of cost on prescribing.

With prescribing expenditure rising and evidence of prescribing costs variation, general practitioners (GPs) in the UK are under increasing pressure to contain spending. The introduction of cash-limited, unified budgets and increased monitoring of prescribing within Primary Care Organizations (PCO) are intended to increase efficiency and enhance GPs financial responsibility. Whilst GPs regularly receive data on the costs of their prescribing and also performance against a set prescribing budget, little is known about the extent to which GPs take cost into account in their prescribing decisions. This study undertook a qualitative exploration of the attitudes of various stakeholders on the relative importance and influence of cost on general practice prescribing. In order to explore a plurality of perspectives, data were obtained from focus groups and a series of individual semi-structured interviews with GPs and key PCO stakeholders. The data suggest that although almost all GPs believed costs should be taken into account when prescribing, there was great variation in the extent to which this was applied and to how sensitive GPs were to costs. Cost was secondary to clinical effectiveness and safety, whilst individual patient need was emphasized above other forms of rationality or notions of opportunity costs. Conflict was apparent between a PCO policy of cost-containment and GPs' resistance to cost-cutting. GPs largely applied simple cost-minimization while cost-consideration was undermined by contextual factors. Implications for research and policy are discussed.

New drug uptake: qualitative comparison of high and low prescribing GPs' attitudes and approach.

BACKGROUND: Prescribing varies considerably between GPs, and a minority of GPs account for a large proportion of new drug prescribing. OBJECTIVE: Our aim was to explore the differences in approach and attitudes towards new drug prescribing between high and low GP prescribers. METHODS: Semi-structured interviews were undertaken with 30 GPs who were either high or low prescribers of new drugs. Interview topics included reasons for prescribing new drugs; use of information sources; attitudes and approach to drug innovation; and consideration of the balance of risk and therapeutic benefit. RESULTS: Differences in GPs' appraisal of new drugs enabled the development of a classification of attitudes and approaches applying to high and low prescribers. Difference in the behaviours of each group is a matter of degree of attitude or influence rather than (usually) its absence. Key dimensions in the classification are attitudes towards new drug prescribing, perception of risk and benefits, strategies adopted for risk management, information-seeking behaviour and use of the pharmaceutical industry as a significant information source. CONCLUSION: Variability in GP prescribing of new drugs relates not only to levels of acquired knowledge, but also to differences in subjective and ideological beliefs.

Understanding why GPs see pharmaceutical representatives: a qualitative interview study.

BACKGROUND: Doctors are aware of the commercial bias in pharmaceutical representative information; nevertheless, such information is known to change doctors' prescribing, and augment irrational prescribing and prescribing costs. AIM: To explore GPs, reasons for receiving visits from pharmaceutical representatives. DESIGN OF STUDY: Qualitative study with semi-structured interviews. SETTING: One hundred and seven general practitioners (GPs) in practices from two health authorities in the North West of England. RESULTS: The main outcome measures of the study were: reasons for receiving/not receiving representative visits; advantages/disadvantages in receiving visits; and quality of representative-supplied information. Most GPs routinely see pharmaceutical representatives, because they bring new drug information speedily; they are convenient and accessible; and can be consulted with a saving of time and effort. Many GPs asserted they had the skills to critically appraise the evidence. Furthermore, the credibility and social characteristics of the representative were instrumental in shaping GPs' perceptions of representatives as legitimate information providers. GPs also received visits from representatives for reasons other than information acquisition. These reasons are congruent with personal selling techniques used in marketing communications. CONCLUSIONS: The study draws attention to the social and cultural contexts of GP-representative encounters and the way in which the acquisition of pharmacological information within the mercantile context of representative visits is legitimated. This highlights the need for doctors to critically appraise information supplied by representatives in relation to other information sources.

Influences on GPs' decision to prescribe new drugs-the importance of who says what.

OBJECTIVES: The aim of this study was to understand the range of factors that influence GPs' uptake of new drugs METHODS: A total of 107 GPs selected purposively from high, medium and low new drug prescribing practices in two health authorities in the north west of England were interviewed using the critical incident technique with semi-structured interviews. Interview topics included reasons for prescribing new drugs launched between January 1998 and May 1999; reasons for prescribing the new drug rather than alternatives; and sources of information used for each prescribed drug. RESULTS: Important biomedical influences were the failure of current therapy and adverse effect profile. More influential than these, however, was the pharmaceutical representative. Hospital consultants and observation of hospital prescribing was cited next most frequently. Patient request for a drug, and patient convenience and acceptability were also likely to influence new drug uptake. Written information was of limited importance except for local guidelines. GPs were largely reactive and opportunistic recipients of new drug information, rarely reporting an active information search. The decision to initiate a new drug is heavily influenced by 'who says what', in particular the pharmaceutical industry, hospital consultants and patients. The decision to 'adopt' a new drug is clinched by subsequent personal clinical experience. CONCLUSIONS: Prescribing of new drugs is not simply related to biomedical evaluation and critical appraisal but, more importantly, to the mode of exposure to pharmacological information and social influences on decision making. Viewed within this broad context, prescribing variation becomes more understandable. Findings have implications for the implementation of evidence-based medicine, which requires a multifaceted approach.