Devolving healthcare services redesign to local clinical leaders: does it work in practice?

Large scale healthcare facility redevelopment: A scoping review

Internationally, organisations are undertaking large scale facility redevelopment as a strategy for the transformation of care systems. Redeveloping facilities provides a once in a generation opportunity to transform health service delivery, typically, however, system level changes are poorly understood. To address this gap, our aim was to investigate the empirical knowledge base regarding large scale redevelopment of healthcare facilities. A scoping review was undertaken, guided by the redeveloped health service management (HSM) scoping review framework (HSM-SRF). Across 17 articles, five key concepts were identified, and they form the principles for successful redevelopment. First, establish a strong governance framework integrating diverse expertise and evidence base. Second, engage with internal and external stakeholders to build effectual relationships. Third, consult with end users, including clinicians and patients, to encourage the acceptance of the redevelopment and actively manage stakeholder dynamics, including politics and power undercurrents. Fourth, commit appropriate resources, including time, workforce, technology and finance to ensure redevelopment success. Finally, reimagine workflows through consultation with end users, including staff and consumers, allowing them to conceptualise how the space will be utilised. This scoping review is the first to synthesise the empirical knowledge base of the redevelopment of healthcare facilities.

Change starts with me: an impact evaluation of a multiprofessional leadership programme to support primary care networks in the South East of England

Purpose

This paper aims to present the impact evaluation findings from a multiprofessional leadership programme commissioned in the South East of England to support primary care networks (PCNs) to lead system improvement together. It identifies programme impact at micro and meso system levels; a leadership impact continuum that can be used by individuals and teams to evidence impact of improvements in PCN practices; the learning and development strategies that were effective and proposes implications for other networks.

Design/methodology/approach

Mixed methods underpinned by practice development methodology were used to explore the impact of the programme on two practitioner cohorts across 16 PCNs. Data were collected at the start, mid-point and end of the eight-month programme.

Findings

Results illustrate an innovative approach to collective leadership development. A continuum of impact created with participants offers insight into the journey of transformation, recognising that “change starts with me”. The impact framework identifies enablers, attributes and consequences for measuring and leading change at micro, meso and macro levels of the health-care system. Participants learned how to facilitate change and collaboratively solve problems through peer consulting which created a safe space for individuals to discuss workplace issues and receive multiprofessional views through action learning. These activities enabled teams to present innovative projects to commissioners for service redesign, enabling their PCN to be more effective in meeting population health needs. The authors believe that this programme may provide a model for other PCNs England and other place-based care systems internationally.

Originality/value

This study offers insight into how to enable a journey of transformation for individuals and PCN teams to enhance team effectiveness and collective leadership for system-wide transformation required by the National Health Service Long Term Plan (2019).

Contribution to Impact

Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study

OBJECTIVE

The increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The Primary Care Network (PCN) policy was promulgated as a model of care to organise private general practitioners (GPs) into groups to provide GPs with resources to anchor patients with chronic conditions with them in the community. As PCN is still in its embryonic stages, there is a void in research regarding its ability to empower GPs to manage patients with chronic conditions effectively. This qualitative study aims to explore the facilitators and barriers for the management of patients with chronic conditions by GPs enrolled in PCN.

DESIGN

We conducted 30 semistructured interviews with GPs enrolled in a PCN followed by a thematic analysis of audio transcripts until data saturation was achieved.

SETTING

Singapore.

RESULTS

Our results suggest that PCNs facilitated GPs to more effectively manage patients through (1) provision of ancillary services such as diabetic foot screening, diabetic retinal photography and nurse counselling to permit a 'one-stop-shop', (2) systematic monitoring of process and clinical outcome indicators through a chronic disease registry (CDR) to promote accountability for patients' health outcomes and (3) funding streams for PCNs to hire additional manpower to oversee operations and to reimburse GPs for extended consultations. Barriers include high administrative load in maintaining the CDR due to the lack of a smart electronic clinic management system and financial gradient faced by patients seeking services from private GPs which incur higher out-of-pocket expenses than public primary healthcare institutions.

CONCLUSION

PCNs demonstrate great promise in empowering enrolled GPs to manage patients with chronic conditions. However, barriers will need to be addressed to ensure the viability of PCNs in managing more patients in the face of an ageing population.

‘Not one action but many’: institutional work by commissioners of children's mental health services in the English NHS

This article enhances our understanding of institutional work, through a study of professional health commissioners in the English National Health Service. Using a case study of mental health policy implementation, commissioners are conceptualized as institutional agents involved in shaping the organizational field and its boundary. Health service commissioners face a series of challenges as institutional agents. Commissioning is a relatively new health profession. It lacks a strong professional association and has predominantly been externally professionalized. Commissioners have limited direct organizational strategic management control. In the case study, commissioners were charged with leading implementation of the policy, which required them to address fragmentation in the field. Using existing typologies as an analytical frame, activities by commissioners in the case study are identified and explored as different modes of institutional work. Commissioners created a new normative network and instigated specific processes to embed and routinize cross-organization working. They undertook boundary-spanning cognitive institutional work, creating new knowledge by commissioning education of school staff in the basics of children’s mental health. Their institutional work involved challenging existing working practices, both in the health field and in the contiguous education field. The article elucidates connections between different modes of institutional work and attends to boundary work by commissioners in parallel with institutional work in the field. It also outlines how a profession seemingly lacking many of the ingredients of institutional power might pursue its own professional project through institutional work. Findings have resonance in other geographical and policy areas and fields.

Implementing integrated care pilot projects in hospital settings – an exploration of disruptive practices

Purpose

In Canada, integrated care pilot projects are often implemented as a local reform strategy to improve the quality of patient care and system efficiencies. In the qualitative study reported here, the authors explored the experiences of healthcare professionals when first implementing integrated care pilot projects, bringing together physical and mental health services, in a community hospital setting.

Design/methodology/approach

Engaging a qualitative descriptive study design, semi-structured interviews were conducted with 24 healthcare professionals who discussed their experiences with implementing three integrated care pilot projects one year following project launch. The thematic analysis captured early implementation issues and was informed by an institutional logics framework.

Findings

Three themes highlight disruptions to established logics reported by healthcare professionals during the early implementation phase: (1) integrated care practices increased workload and impacted clinical workflows; (2) integrating mental and physical health services altered patient and healthcare provider relationships; and (3) the introduction of integrated care practices disrupted healthcare team relations.

Originality/value

Study findings highlight the importance of considering existing logics in healthcare settings when planning integrated care initiatives. While integrated care pilot projects can contribute to organizational, team and individual practice changes, the priorities of healthcare stakeholders, relational work required and limited project resources can create significant implementation barriers.