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This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed trusted 20mg tadora erectile dysfunction internal pump, the full report) may be included in professional journals xix provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising order tadora 20mg mastercard erectile dysfunction treatment clinics. Applications for commercial reproduction should be addressed to: NIHR Journals Library cheap tadora generic erectile dysfunction young male, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Institutions are maintained by established interests using devices (such as professional boundaries), bureaucratic mechanisms (such as job evaluations and job grades) and cultural mechanisms (such as beliefs and norms). Yet, as we show in this report, institutional work can involve modification of existing institutions and the creation of new ones. This interplay between defence routines, disruption and innovation is in many ways the story of the CCGs. The building of institutions is underpinned by logics. Thus, a market logic requires plural agents able to compete on price and other bases, such as quality. A bureaucratic logic uses plans, rules and division of labour. A network logic relies on collaboration and negotiation. The very creation of CCGs was itself an outcome of institutional work – in this case work done at the parliamentary level led by a particular Secretary of State. The institutions created had a bias towards a logic of efficiency driven through competition, but the details of how the new institutions should operate in practice were left somewhat open. Hence, much more institutional work was required at a local level. However, they were faced not with a blank sheet but with a set of existing institutions whose agents often sought to protect current arrangements. In addition, crucial to the account given in this report, other institutional work designed to drive other changes to the health-care system can be seen to overlay and compete with the focal initiatives. Research methods The project proceeded in five phases. The first of these was an extensive scoping study across 15 CCGs from different parts of England covering major urban areas and rural locations. The second phase and component was the design and administration of a first national survey of all members of CCG governing bodies. This was undertaken in 2014 and had a response from 79% of all CCGs (12. The third phase was a major piece of work involving six main in-depth case studies. The national survey was used as a sampling frame, and this allowed investigation of a range of cases that illuminated selective aspects of clinical leadership in action in a variety of contexts. The fourth phase was a second national survey of governing body members, which was conducted in 2016. This survey allowed longitudinal comparisons and had a response rate of 77. The fifth phase was devoted to a set of international comparisons of findings and their interpretation in dialogue with different sets of international experts. We sought to involve public and patients as far as was relevant and practicable at all stages. In the first instance, a nationally renowned patient and public involvement (PPI) representative, with very extensive experience of PPI, was appointed as co-chairperson of the Project Steering Committee. This representative was involved in all aspects of the research from the initial design to the discussions about dissemination of findings. During the course of the project, PPI was used mainly in relation to the specific service redesign initiatives that were the focal component of this study. These initiatives often had PPI arrangements in place and we tapped into these, rather than seeking to set up new arrangements. One extension of this approach was that a member of the project team sought permission to become an active participant member of a PPI group that was associated with one of the service redesign initiatives in the core case studies. Full ethics approval from the Research Ethics Committee overseeing the project was sought and full disclosure was made to members of the PPI group. Findings relating to Clinical Commissioning Groups l A number of CCGs were relatively passive. In these instances neither GPs nor managers had evidenced any scale of ambition for service change. However, other CCGs had been more active and had made an impact on secondary care, primary care or both. Others had concentrated on collaborative working with existing providers in pursuit of new patterns of care. London: NHS England; 2014) and its associated new models of care and the sustainability and transformation plans (STPs), were increasingly relocating much of the inventiveness from CCGs into other hands. Findings relating to clinical leadership l Clinical leadership in and around CCGs is different in nature from that found in hospital settings where professional bureaucracies are entrenched. In the CCG context, cross-boundary intercession and negotiation across professional groups and across organisational boundaries is required. However, effective and sustained service redesign required matching, mutually reinforcing and commensurate action across all three arenas. Clinical leadership is required in at least one of these. Clinical and managerial leaders in this kind of board played a vital role in mediating between different managerial and clinical perspectives characteristic of arenas within the NHS. This defining work often involves rethinking the interfaces between previously overdefined and separate services that have become established under a contract-driven and somewhat adversarial model of commissioning. Issues of continued viability of particular provider organisations may need to be faced, but this is more likely to be done effectively if commissioners join providers in thinking through what a viable future might look like for them. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals xxi provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. SCIENTIFIC SUMMARY The research found that, despite the limitations to the expected institutional work of service redesign using local commissioning, some clinicians in and around CCGs did rise to the challenge and seized the opportunity to find ways to create new and/or amended institutions. The report draws out the lessons from these more creative attempts. The processes of leadership, which we reveal in three different arenas (strategic, operational planning and service delivery), are illustrated in the context of CCGs; however, they also have relevance and carry lessons far beyond these particular institutions. CCGs happen to provide the natural experimental conditions, but how the dynamics of the interplay between policy-makers, managers and clinicians actually play out is of central relevance. Lessons can therefore be learned that go beyond these particular circumstances. Novel examples of active clinical leadership in new forms of service design were uncovered. These occurred at different levels and in different arenas, and the patterns are described and illustrated in this report. At the other extreme, many CCGs struggled even to find GPs willing to serve on CCG governing bodies.

Three splice variants of the CRF-2 receptor subtype buy discount tadora 20 mg online erectile dysfunction diabetes, nonpeptidic antagonists of the CRF-1 receptor such as CP the CRF-2 generic tadora 20mg amex doctor who treats erectile dysfunction, CRF-2 buy cheap tadora on line erectile dysfunction treatment injection, and CRF-2 , and two splice variants 154,526 (18) have provided important pharmacologic tools of the CRF-1 receptor, have been identified (9). Molecular for the analysis of CRF-1 receptor function. Mutation stud- characterization studies have demonstrated that there is ap- ies have demonstrated that peptide and nonpeptide antago- proximately a 70% sequence homology between CRF-1 and nists bind to different domains of the CRF-1 receptor (9). Cloning of the human CRF-2a To date, selective CRF-2 antagonists have not been de- gene revealed that it is 94% identical to the rat CRF-2 scribed, though recently, nonpeptide dual antagonists of the receptor and 70% identical to the human CRF-1 receptor. There is currently no evidence of the existence of the CRF- In addition to CRF receptor subtypes, another potential 2 receptor in humans. CRF- ogy and different localizations in the brain and periphery. In BP is a specific carrier for CRF and related peptides found situ hybridization and receptor autoradiography techniques in human plasma and brain. CRF-BP is thought to be a been used to map the relative distributions of CRF-1 and modulator of CRF activity. The CRF-BP is found in high CRF-2 receptors in the rat brain (11,12). High expression densities in the rat amygdala, cortex, and bed nucleus of of CRF-1 receptors was seen in the pituitary, and in a num- the stria terminalis. In contrast, high densities of CRF-2 are found in more circumscribed regions, includ- Studies utilizing transgenic and knockout mouse models ing the lateral septum, ventromedial nucleus of the thala- have provided important information with regard to the mus, and choroid plexus. Moderate densities of CRF-2 re- contribution of CRF and CRF receptor subtypes to pro- ceptors were reported for the medial amygdala and dorsal cesses including energy balance, emotionality, cognition, raphe nucleus. Further characterization has indicated that and drug dependence (20). This chapter focuses on the evi- the CRF-2 splice variant accounts for the brain localization dence implicating CRF and CRF receptors in anxiety states. Urocortin, rather than CRF, most closely maps xiogenic effects using either the black-white box test (21) to CRF-2 receptors, leading to the suggestion that it may or the elevated plus maze (22). The latter effect was reversed be the endogenous ligand for CRF-2 receptors. Recent work by central administration of the CRF receptor antagonist has shown that the distribution of CRF-2 receptors may -helical CRF, but not by adrenalectomy, supporting the differ significantly in the nonhuman primate brain relative role of central CRF pathways independent of the HPA axis to the rodent brain such that the CRF-2 subtype may play (22). Studies using antisense directed against CRF in rats a more significant role than previously thought (13). Finally, CRF receptors utilize 3′,5′-cyclic adenosine monophos- overexpression of CRF-BP is anxiolytic, whereas binding phate (cAMP) as a second messenger in the pituitary and protein knockout mice (in which free CRF levels are ele- brain and can be regulated by chronic activation. Thus, vated) display an anxiogenic phenotype in the elevated plus Chapter 68: Mechanism of Action of Anxiolytics 995 maze (24). These data generally support the link between Of the compounds listed above, the compound discov- CRF and anxiety. A recent report (37) describes results 1 knockout mice demonstrated a diminished anxiogenic re- from a phase II, open-label, dose-escalating trial in which sponse on the elevated plus maze and decreased ACTH 20 severely depressed (Hamilton Depression Score 25) and corticosterone responses to restraint stress (25). Similar patients were administered R-121919 in one of two dose findings were reported by Timpl et al. Furthermore, inactivation of 50% of the patients responded positively to treatment as the CRF-1 receptor with an antisense oligonucleotide was indicated by a reduction in the Hamilton Depression Score shown to reduce the anxiogenic effect of intraventricularly of at least 50%, and 20% were remitters (score 8). In addition, no significant untoward side ity from CRF-1 antisense that was chronically infused into effects were reported, and basal or stress-induced levels of the central nucleus of the amygdala, an area of the limbic ACTH or cortisol where unaffected, suggesting that chronic system shown by Michael Davis, Joe LeDoux, and others blockade of the HPA axis might not necessarily produce to be important in mediating fear and anxiety processes. Although these preliminary data are Finally, CRF-2 knockout mice showanxiety-like behavior promising, it is important to bear in mind that they were and are hypersensitive to stress (28), indicating that the gathered using an open label design without placebo con- CRF-2 receptor has an opposite functional role to that of trol. Firm conclusions regarding the efficacy and safety of the CRF-1 receptor. Thus, it could be argued that CRF-2 CRF-1 antagonists in depression and anxiety will require agonists, rather than antagonists, might be potentially useful more rigorous double-blind, placebo-controlled trials. Several lines of evidence suggest that ences has announced that further candidates are being pur- during the period of withdrawal from drugs of abuse such sued for clinical evaluation. Anxiety is among the many physical have not been described, though recently, nonpeptide dual symptoms of drug withdrawal, and given the link that has antagonists of CRF-1 and CRF-2 receptors have been de- been made between CRF and anxiety, it is not surprising scribed (19). As there is contradictory evidence regarding that CRF-1 receptor knockout mice demonstrated de- the role of CRF-2 receptors in mediating anxiety, careful creased anxiety responses during withdrawal from alcohol preclinical and clinical evaluation of these compounds will (26). Current Drugs in Development A number of nonpeptidic, small-molecule compounds that Future Drugs and Directions showhigh selectivity for the CRF-1 receptor have been pro- posed for the treatment of depression, anxiety, and stress As indicated above, a number of drug companies have dedi- disorders (29–31). These include CP-154,526 (Pfizer), and cated significant efforts to identifying potent and selective a methylated analogue, antalarmin (Pfizer); SC 241 (Du- CRF-1 receptor antagonists suitable for clinical develop- pont); NBI 30775 (aka R-121919; Janssen-Neurocrine); ment. To date, no compounds have completed phase II and CRA 1000 and CRA 1001 (Taisho Pharmaceuticals). Clearly, a challenge for the future will be to An extensive preclinical literature has investigated potential achieve this milestone and, in the process, validate with anxiolytic effects of these compounds. Studies using CP- carefully executed clinical trials the concept that CRF-1 re- 154,526 have demonstrated anxiolytic-like effects in some ceptor antagonists are novel anxiolytics and/or antidepres- (32–34) but not all (33,34) preclinical anxiolytic paradigms sants. Also, given increasing evidence of the importance of evaluated. CP-154,526 produces an anxiolytic It will be of interest to determine if agonists, rather than effect in the separation-induced vocalization assay (35), an antagonists, of the CRF-2 receptor have anxiolytic profiles. At (BENZODIAZEPINES AND RELATED DRUGS) present, almost 20 different cDNAs have been identified and classified into six classes based upon sequence homol- A majority of the synapses in the mammalian CNS use the ogy. Cloned from vertebrates, there are six , four , four amino acids l-glutamic acid, glycine, or -aminobutyric acid , one , one , and two subunits and some splice variants; (GABA) for signaling. GABA is formed by the decarboxyl- the subunits share a basic motif where the amino acids span ation of l-glutamate, stored in neurons, and released, and the membrane four times. Because of these findings, it has Extensive mutagenesis and structural examination has been accepted for over 20 years that GABA fulfills the char- been carried out with the GABA and acetylcholine family acteristics of a neurotransmitter (38). Acetylcholine receptors have been mate, acetylcholine, and serotonin, GABA possesses two shown to possess a pentameric subunit structure with a het- different types of receptor conserved across different species erogeneous subunit composition; evidence for this conclu- and phyla that control both excitation and inhibition. Similar sion (ionotropic) and metabolism (metabotropic) are electron microscopic analysis of GABAA receptors has been mediated by proteins in two different superfamilies. It is thought that the native GABAA recep- first superfamily (GABA receptors) is a set of ligand-gated tors also possess such a pentameric structure with general A ion channels (ligand-gated superfamily) that convey composition of 2 ,2 , and one subunit forming the majority of the GABAA receptors in vertebrates. When a of this has been more circumstantial, generated by molecular GABAA receptor is activated, an ion channel is opened biological and pharmacologic inferences, described below, (gated) and this allows chloride to enter the cell; the usual and by the behavior of solubilized recombinant complexes result of chloride entry is a slowing of neuronal activity on sucrose gradient centrifugation in the presence and ab- through hyperpolarization of the cell membrane potential. Through their activity quence forms the actual ion channel of acetylcholine recep- on other effector systems, G proteins can change second tors, and that mutations of amino acids at the inner (cellu- messenger levels, altering signal transduction and gene lar) side of the membrane are responsible for the ability of expression, or open ion channels that are dependent on specific cation ions to pass through the channel pore (48). Both excitatory and The ionic selectivity can be changed by altering the charge inhibitory activities are possible on a time scale that is longer of some of these specific amino acids, and the acetylcholine than GABAA receptor mediated events. There is extensive receptor can be forced to gate chloride, rather than sodium, heterogeneity in the structure of the GABAA receptor mem- by such changes. Thus, a relatively firm case for the involve- bers of the ligand-gated superfamily. These receptors are ment of this spanning region in the formation of the ion the targets of a number of widely used and prescribed drugs channel can be made. Because the core ion pore is highly for sleep, anxiety, seizure disorders, and cognitive enhance- conserved among the large number of GABA receptor sub- A ment; they may also contribute to mediating the effects of types, a number of drugs that interact nonspecifically with ethanol on the body.

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Persecutory (or paranoid) delusions include that the individual is being harassed buy tadora erectile dysfunction houston, threatened cheap tadora master card erectile dysfunction psychogenic causes, watched or bugged purchase 20mg tadora with mastercard erectile dysfunction doctor michigan. They often involve spies, bikies, God, Satan or neighbours. Delusions of reference are the belief that the everyday actions of others are premeditated and made with special reference to the patient. Commonly patients complain about being talked about on television or the radio. Patients may believe that music played or words spoken on television have been specifically chosen to identify or annoy them. People crossing the street or coughing may be interpreted as making purposeful actions, performed to indicate something to, or about, the patient. Nihilistic delusions are the belief that part of the individual or the external world does not exist, or that the individual is dead (Cotard syndrome, see later). Financially comfortable individuals may believe they are destitute, in spite of bank statements to the contrary. Patients who believe they have no head or are dead, are unable to explain how that could be possible, but still hold the belief. A bizarre example is when the individual believes his nose is made of gold. A non- bizarre example is when the individual believes he has cancer of the rectum, in spite of negative reports from a competent doctor who has examined the rectum. Delusions of infestation/parasitosis are not uncommon in dermatological clinics (Hylwa et al, 2011). Delusions of guilt - that the individual is guilty of purposefully or non-purposefully damaging themselves, other individuals or important property. Individuals may believe they are guilty of causing the cancer of the lady who lives next door, or a drought in Central Africa. Erotic delusions (erotomania) - the belief of the patient that another person is in love with him/her (de Clerambault syndrome, see later). This (among others) may be a motivation for stalking, and lead to contact with the unwelcoming central figure of the delusion. Last modified: November, 2015 3 Systematized delusions are united by a single theme. They are often highly detailed and may remain unchanged for years. Non-systematized delusions may change in content and level of concern, from day to day or even from minute to minute. The above “public notice” was part of a one page document widely distributed throughout an Australian capital city by its writer. The full document is not presented because the second half made accusations against named people. The writer believed the owners of a coffee lounge were persecuting him. He was jailed and died in prison, by suicide, days later. Prominent pathological features were the bizarre and persecutory delusional material, and that while disorder of the form of thought (loss of logical connections) made the delusion difficult to follow, it was systematized and remained relatively unchanged over time. This is a passage from a biography written by a man who subsequently drowned himself. The injections referred to are injections of long-lasting antipsychotic medication. These “depot” medications help prevent relapse in psychotic disorders and can be given once every few weeks. After this man had ceased his injections for six Pridmore S. Last modified: November, 2015 4 months and his body was completely free of antipsychotic medication, he began to misinterpret the environment in a persecutory manner. He believed his friends had been “backbiting” and that a church leader (whose name has been replaced with “Anonymous”) said that he should be in prison. It is reasonable to conclude that the clergyman used the name Peter by mistake and the patient failed to recognize the mistake, and concluded instead, that this misuse was purposeful. Another possibility is that the patient was hallucinating when he heard the name Peter and the comment that he (the patient) should be in prison. The two documents above, along with a CD of other documents, were mailed to many neurosurgeons and psychiatrists at leading hospitals around Australia. The writer provided full contact details and welcomed any response. He believed that an implant was placed in his head by the CIA in 1999 and it had caused him to attempt suicide. He attributed various events over the years (Deaths of Princess Diana, Dr David Kelly, and others) to the same process. These beliefs have the hallmarks of a detailed delusional system which may have been present for some years. The second letter is a response to this individual from the Australian Federal Police. He had written to them regarding his beliefs, and they responded stating they were unable to help with his complaint. Named delusions This section is added for completeness. Mention is made of some delusions which get quite a bit of attention in some books, because they are exotic and interesting. However, they are rare and are managed as are any other delusion. They do provide a fascinating window into psychosis. Capgras syndrome is the delusion that a person (usually a family member or someone close to the patient) has been replaced by an impostor of nearly identical appearance. This most commonly occurs in schizophrenia and organic brain disease. Last modified: November, 2015 6 de Fregoli syndrome is the delusion that a person (usually a suspected tormentor) can change into different people, and many of the people the patient meets are misidentified as transformed version of the suspected person. The issue may be whether the person who is misidentified is known or unknown to the patient. Folie a deux (shared psychotic disorder) is diagnosed when two people share the same delusion (Shimizu et al, 2007). Usually one of these people is psychotic and the second is not psychotic; but the non-psychotic person has come to accept what the psychotic person believes. It is common for the psychotic person to have been intelligent and authoritative, and for the non-psychotic individual to be somewhat dependant. The psychotic person should be managed in the normal manner. When removed from the influence of the psychotic person, the non-psychotic individual rapidly gains “insight”.

The questionnaire was a combination of structured questions and a set of more open-ended questions with space for free-form answers buy genuine tadora on-line erectile dysfunction age 18. There was a very high response to the free-form questions – with 96% of respondents taking time to write in these sections discount tadora 20 mg line erectile dysfunction weight loss. This was a strong indication of the extent to which respondents were engaged with the questionnaire and found it relevant and interesting purchase cheap tadora line erectile dysfunction caused by steroids. The respondents were keen to express their views and many did so with passion. Copies of the questionnaire can be found in Appendix 3. The profile of respondents As can be seen from Figure 1, responses were received from all role categories with the numbers broadly reflecting the relative numbers sitting in these boards. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 19 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE NATIONAL SURVEYS 30 25 20 Year 2014 15 2016 10 5 0 FIGURE 1 Roles of respondents. The first thematic question examined was the perceived influence of CCGs. We wanted to understand what respondents thought was the scope to make a difference through these institutions. Perceived influence of Clinical Commissioning Groups The first main substantive question asked about the perceived influence of CCGs relative to other NHS organisations. The reason for asking about this was that the overall research question was essentially about the scope for leadership influence using CCGs as an institutional platform. We asked board members to make a comparison of the perceived influence of their CCG relative to other bodies such as NHSE and NHS trusts. The form of the question asked for a rank ordering of the bodies most influential in shaping local health services. Half of the respondents judged that their CCG was the most influential in this regard, and NHSE was ranked second. However, nearly half of the respondents did not rate their own CCG as the most influential. NHSE was seen as the next most influential institution in shaping service redesign and the growing importance of collaboration between CCGs is also indicated. However, the fact that nearly half of CCG board members themselves judged that their CCG did not exercise the most influence might be expected to be a potential curb on expectations about the exercise of leadership by CCG clinicians or other CCG players. The data for the assessment of influence split by role holder are shown in Figure 3. Notably, it was the chairpersons of CCGs who were most likely to perceive their CCGs as influential. However, other role holders, most notably finance directors, did not. Less than half of accountable officers perceived their CCG to be the most influential body in shaping services. This is an especially important finding because arguably, among all of the different role holders, one would expect the accountable officers to have the clearest line of sight on the various forces at play. It would suggest that the reality of CCG influence is rather less than was implied by the policy intent as it was described at the outset of this report. Many GPs on CCG boards reported that they were disillusioned with their CCG experience. For example: The CCG is becoming increasingly bureaucratic and much more like a PCT. We are increasingly subject to government directives and with short deadlines. There is no space for creative solutions from the CCG. GP member of governing body We then undertook a different analysis: the perceived relative influence of different bodies was correlated with the ratings of CCGs allocated by NHSE. It may be that the pattern of institutional influence is reflected in 100 90 80 Other Patients 70 Hospitals and other providers 60 My local HWB My CCG in collaboration with 50 some neighbouring CCGs 40 Various regulators NHSE 30 My CCG 20 10 0 FIGURE 3 Relative influence of different bodies as reported by different role holders. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 21 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE NATIONAL SURVEYS 100 90 80 Other 70 Patients Hospitals and other providers 60 My local HWB 50 My CCG in collaboration with some neighbouring CCGs 40 Various regulators 30 NHSE My CCG 20 10 0 Inadequate Requires Good Outstanding improvement FIGURE 4 The relative influence of different bodies (2016) by NHSE headline rating of the CCG. Alternatively, it may be that this pattern suggests the possibility of a self-fulfilling prophesy: those expecting low impact achieved just such; conversely, those assuming that they had influence were able to exercise it. There is an alternative explanation: the low and high performers sensed the state of play and disowned or owned responsibility accordingly. Figure 5 shows comparative data for 2014/16 with regard to perceived influence on the design of services in the local health economy. There certainly seemed to be no sense of a growing influence. The largest group of respondents said that their own CCG was the major player (38% of influence in 2016). However, other bodies were also seen as important, and these included NHSE (14%) and local collaborations of CCGs (18%). There were significant differences in this assessment depending on the role of the respondent with regard to their views about NHSE and NHS Improvement. GP members of the governing bodies were most likely to perceive NHSE and NHS Improvement as influential. Next we looked at ratings of CCGs by perceived importance of collaboration among neighbouring CCGs. And perhaps they did not want to collaborate with others in case this affected their performance ratings. When asked to rate the influence exerted by hospitals and other providers, it tended to be respondents from CCGs rated as inadequate who were more likely to accord the highest influence to these bodies (Figure 7). This may reflect the reality of powerful local hospital trusts or it might reflect a lack of will or capability in tackling these providers. The next section shifts focus from the influence of CGGs to an analysis of relative influence within them. Most especially, there was the contentious issue of whether managers or clinicians were exercising power and, relatedly, what influence, if any, other role holders such as the lay members, the secondary care doctors and the nurses had. Influence within Clinical Commissioning Groups Given that the policy intent, as shown in Chapter 1, was to create commissioning organisations led by clinicians – and most especially by GPs – we wanted to know whether or not these institutions had lived up to that aspiration. We began with a question which asked about the relative influence of different groups on the redesign of services.

By X. Kapotth. Clearwater Christian College.