The "redisorganisation" of the NHS

Scale and spread of innovation in health and social care: Insights from the evaluation of the New Care Model/Vanguard programme in England

OBJECTIVE

Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model - or 'Vanguard' - programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up.

METHODS

We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation.

RESULTS

A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models.

CONCLUSIONS

This programme is an example of the 'scale and spread paradox', in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions

Background

Policy-makers expect that integration of health and social care will improve user and carer experience and reduce avoidable hospital use. [We] evaluate the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes. The latter had far greater financial and expert support from central agencies.

Methods

Of the 206 Clinical Commissioning Groups (CCGs) in England, 51(25%) were involved in the Pioneer programme only, 22(11%) were involved in the Vanguard programme only and 13(6%) were involved in both programmes. We used quasi-experimental methods to compare monthly counts of emergency admissions between four groups of CCGs, before and after the introduction of the two programmes.

Results

CCGs involved in the programmes had higher monthly hospital emergency admission rates than non-participants prior to their introduction [7.9 (95% CI:7.8–8.1) versus 7.5 (CI: 7.4–7.6) per 1000 population]. From 2013 to 2018, there was a 12% (95% CI:9.5–13.6%) increase in emergency admissions in CCGs not involved in either programme while emergency admissions in CCGs in the Pioneer and Vanguard programmes increased by 6.4% (95% CI: 3.8–9.0%) and 8.8% (95% CI:4.5–13.1%), respectively. CCGs involved in both initiatives experienced a smaller increase of 3.5% (95% CI:-0.3–7.2%). The slowdown largely occurred in the final year of both programmes.

Conclusions

Health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term. Greater financial and expert support from national agencies and involvement in multiple integration initiatives can have cumulative effects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06692-x.

Portents from Orwell's 1984: Bureaucracies, Ministries of Truth and Plenty - challenges facing the administration of mental healthcare in Australia

OBJECTIVE

We reflect upon the processes of mental health administration in Australia with reference to George Orwell's novel, 1984.

CONCLUSIONS

Mental healthcare in Australia is distorted by politicisation, spin and a refusal to acknowledge the reality of the current situation. These challenges for mental healthcare demonstrate some similarities with the Ministries of Truth and Plenty, which conversely performed as their opposites in Orwell's novel. Psychiatrists and their professional bodies should play a greater role in advocacy for clinician-led, evidence-based services in partnership with our communities.

Potemkin redux: the re-disorganisation of public mental health services in Australia

OBJECTIVES

This paper discusses the phenomenon of re-disorganisation as it applies to publicly-funded mental health services. The term refers to the constant reorganisation of services in the absence of evidence and of unclear benefit. We illustrate the problems of re-disorganisation with some hypothetical examples, as well as discussing the context of these problems.

CONCLUSIONS

The re-disorganisation of public mental health services may be considered a politically expedient administrative response resulting in the illusion of activity and progress. It may be intentional or unintentional. Re-disorganisation can detract from effective policy, planning and implementation of improvements in provision of public mental health services.

A Surrealistic Mega-Analysis of Redisorganization Theories

Background

We are sick and tired of being redisorganized.

Objective

To systematically review the empirical evidence for organizational theories and repeated reorganizations.

Methods

We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people's realities. We are sorry about this, but it is not our fault.

Results

We discovered many reasons for repeated reorganizations, the most common being ‘no good reason’. We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives.

Conclusions

We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.

Chief Executives and the Modernization of the English National Health Service

The popular image of an empowered, proactive leader fails to reflect the reality of senior managers’ roles in public sector organizations in the UK at the present time. This point is developed through a study of senior chief executives in the English National Health Service (NHS) between 2000 and 2002 when, in response to perceptions that the Service was in crisis, the New Labour government introduced a ten-year modernization programme backed by substantial increases in public funding. In previous years considerable interest had been shown in the importance of leadership within public sector organizations. However, by the time of this study senior politicians in the UK had become suspicious about the abilities of public sector managers in general, and those within the NHS in particular, to deliver the reforms that they had deemed essential. A series of interviews with NHS chief executives over the 2000-2 period recorded the pressures that they were subjected to: rather than being given the scope to help lead the reform of the NHS, chief executives were treated as little more than conduits for the policies of the centre. The interviews illustrate how undermined and demoralized many of them came to feel. Relating the episode to the broader literature on leaderships it is suggested that the study of leadership in the public sector cannot be divorced from broader study of the institutions of the state and, in this case, from the centralized performance audit regime that government developed to drive forward its modernization policy. In the light of such issues, the article draws attention to the importance of ‘bureaucratic discretion’ to the theory of public sector leadership.

Mobilising knowledge to improve UK health care: learning from other countries and other sectors – a multimethod mapping study

Background

The past two decades have seen rich conceptual development and a wide variety of practical initiatives around research use or ‘knowledge mobilisation’, but so far there has been little systematic effort to map, conceptualise and learn from these initiatives, or to investigate the degree to which they are underpinned by contemporary thinking as set out in the literature. This gap is particularly apparent when looking at knowledge mobilisation at the ‘macro’ level, that is the strategies and activities of major research funders, major research producers and key research ‘intermediaries’.

Aims and objectives

The study had three key objectives with associated research questions: to map the knowledge mobilisation landscape in health care (in the UK and internationally) and in social care and education within the UK; to understand the models, theories and frameworks that underpin the approaches to knowledge mobilisation; and to learn from the success or otherwise of the strategies and approaches in use.

Methods

The study was multimethod and multiphased, with considerable interactivity between the different strands. Data were collected through a review of 71 published reviews on knowledge mobilisation; website review of the knowledge mobilisation activities of 186 agencies; in-depth interviews (n = 52) with key individuals in agencies; a web survey (response rate 57%;n = 106); and two stakeholder workshops (at months 6 and 16).

Findings

We identified a wide range of models, theories and frameworks used to describe knowledge mobilisation and created a conceptual map that highlights six domains of thinking and debate in the literature. The interview and survey data showed three broad, overlapping roles undertaken by agencies: developing and sharing research-based products; emphasising brokering; and focusing on implementation. The knowledge mobilisation approaches in use had been shaped by many factors but there was only limited use of the models, theories and frameworks from the literature. Participants saw formal evaluation of knowledge mobilisation activities as important but highly challenging. Rich formative experience was described but formal evaluation was relatively rare. Few agencies involved service users or members of the public in knowledge mobilisation activities. Working inductively from the study data we derived eight key archetypes or ‘bundles of knowledge mobilisation activities’ that could be used by agencies to explore their knowledge mobilisation activities, future strategies and stakeholder perspectives.

Conclusions

Knowledge mobilisation could be enhanced by providing support to enable cross-sector and interagency learning, reflection on the conceptual basis of approaches and increased evaluation of knowledge mobilisation activities. Further research is needed to evaluate approaches to assessing research use and impact, on systems approaches to knowledge mobilisation, on sustaining and scaling-up approaches, and on applying a wider range of literatures to knowledge mobilisation. Further research would also be useful on the knowledge mobilisation archetypes and how they can work in complementary ways.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Reforming the culture of healthcare: the case for intelligent kindness

There has been increasing interest in the culture of healthcare in the light of the two reports by Robert Francis into the care at Mid Staffordshire. This editorial encourages a comprehensive exploration of the conditions that promote a benign caring culture and make outbreaks of cruel neglect and abuse of patients less likely. Creating and sustaining such a culture is dependent on being honest and realistic about the forces that threaten to undermine it. The editorial argues that being able to confidently articulate the positive values that should define healthcare culture is particularly important at this time. The case is made for a conscious focus on the concept of intelligent kindness.

Health care agreements as a tool for coordinating health and social services

Introduction

In 2007, a substantial reform changed the administrative boundaries of the Danish health care system and introduced health care agreements to be signed between municipal and regional authorities. To assess the health care agreements as a tool for coordinating health and social services, a survey was conducted before (2005–2006) and after the reform (2011).

Theory and methods

The study was designed on the basis of a modified version of Alter and Hage's framework for conceptualising coordination. Both surveys addressed all municipal level units (n = 271/98) and a random sample of general practitioners (n = 700/853).

Results

The health care agreements were considered more useful for coordinating care than the previous health plans. The power relationship between the regional and municipal authorities in drawing up the agreements was described as more equal. Familiarity with the agreements among general practitioners was higher, as was the perceived influence of the health care agreements on their work.

Discussion

Health care agreements with specific content and with regular follow-up and systematic mechanisms for organising feedback between collaborative partners exemplify a useful tool for the coordination of health and social services.

Conclusion

There are substantial improvements with the new health agreements in terms of formalising a better coordination of the health care system.

Change of Government: One More Big Bang Health Care Reform in England's National Health Service

Once again the National Health Service (NHS) in England is undergoing major reform, following the election of a new coalition government keen to reduce the role of the state and cut back on big government. The NHS has been undergoing continuous reform since the 1980s. Yet, despite the significant transaction costs incurred, there is no evidence that the claimed benefits have been achieved. Many of the same problems endure. The reforms follow the direction of change laid down by the last Conservative government in the early 1990s, which the recent Labour government did not overturn despite a commitment to do so. Indeed, under Labour, the NHS was subjected to further market-style changes that have paved the way for the latest round of reform. The article considers the appeal of big bang reform, questions its purpose and value, and critically appraises the nature and extent of the proposed changes in this latest round of reform. It warns that the NHS in its current form may not survive the changes, as they open the way to privatization and a weakening of its public service ethos.

Relationship between evidence and policy: a case of evidence-based policy or policy-based evidence?

The use (or non-use) of evidence in health policy is an issue of growing interest and concern among both academic researchers and policy makers. Most public health research is government funded, yet the extent to which its findings are used to shape and inform policy is variable in the extreme. Part of the problem lies in the nature of the evidence itself and the extent to which it addresses the complexities of the issue being researched. However, part of it also lies in the way that evidence gets communicated and transmitted to those intended to benefit from, or act on, it. This paper reviews such matters and argues in favour of research that is more attuned to the needs of policy makers and practitioners. To achieve this, a paradigm shift is needed in the way in which research is produced and consumed. Rather than academics exclusively setting the agenda, a new approach to knowledge co-creation is overdue whereby researchers, and those they are seeking to address, work together to define the research questions, agree the methods, and assess the implications of the data analysis and findings for policy and practice.

Pseudoinnovation: the development and spread of healthcare quality improvement methodologies

BACKGROUND

Over the last two decades, we have seen the successive rise and fall of a number of concepts, ideas or methods in healthcare quality improvement (QI). Paradoxically, the content of many of these QI methodologies is very similar, though their presentation often seeks to differentiate or distinguish them.

METHODS

This paper sets out to explore the processes by which new QI methodologies are developed and disseminated and the impact this has on the effectiveness of QI programmes in healthcare organizations. It draws on both a bibliometric analysis of the QI literature over the period from 1988 to 2007 and a review of the literature on the effectiveness of QI programmes and their evaluation.

RESULTS

The repeated presentation of an essentially similar set of QI ideas and methods under different names and terminologies is a process of 'pseudoinnovation', which may be driven by both the incentives for QI methodology developers and the demands and expectations of those responsible for QI in healthcare organizations. We argue that this process has important disbenefits because QI programmes need sustained and long-term investment and support in order to bring about significant improvements. The repeated redesign of QI programmes may have damaged or limited their effectiveness in many healthcare organizations.

CONCLUSIONS

A more sceptical and scientifically rigorous approach to the development, evaluation and dissemination of QI methodologies is needed, in which a combination of theoretical, empirical and experiential evidence is used to guide and plan their uptake. Our expectations of the evidence base for QI methodologies should be on a par with our expectations in relation to other forms of healthcare interventions.

Community nursing: redesign in Scotland

The report 'Visible, accessible and integrated care' (VAIC) proposes a new Community Health Nurse (CHN) model which involves the combination of the four current disciplines of district nursing, public health nursing (health visiting and school nursing) and family health nursing into a single generic role (Scottish Executive, 2006b). The Queen's Nursing Institute in Scotland (QNIS) wished to identify the implications of the VAIC report; a series of national focus groups were held throughout Scotland during 2007 with key stakeholders, initially including managers and senior nurses, practitioners, staff nurses and educationalists, and later family health nurses, practice nurses, school nurses, and General Practitioners. Finally, a patient and carers' focus group was held to establish a public perspective on the changes. This article summarizes the key findings from the QNIS focus groups and highlights the emerging themes concerning the implementation of VAIC.

Evidence-based policy: implications for nursing and policy involvement

Evidence-based policy making is espoused as a central feature of government in the United Kingdom. However, an expectation that this will improve the quality of policy produced and provide a path to increased involvement of nurses in the policy process is misplaced. The purpose of this article is to demonstrate that the emphasis on evidence-based policy is problematic and cannot be regarded as a "new model" of policy making. Also, it could deflect attention from more practical approaches to policy involvement on the part of nurses. Policy development activities, acquisition of skills in policy analysis, and other forms of involvement are needed if nurses are to move along the continuum from policy literacy, through policy acumen, to policy competence. This involves taking a critical stance on the notion of evidence-based policy.

Trusting in the New NHS: instrumental versus communicative action

Recent reforms within the UK National Health Service, particularly the introduction of clinical governance, have been enacted with the apparent aim of rebuilding patient trust. This paper analyses the approach taken by policy makers, arguing that it is based very much on an instrumental conception of trust. The assumptions and limitations of this model are discussed and in so doing, a communicative understanding of trust is proposed as an alternative. It is argued that the instrumental rationality and institutional focus inherent to instrumental trust neglect the importance of the communication between patient and medical professional and its affective dimensions. Communicative trust goes beyond a mere cognitive appreciation of the system and rather is dependent on the qualitative interaction at the access point, where the patient comes to believe that the communicative rationality of their best interests is mirrored by the professional's instrumental rationality. Whilst recent challenges to the confidence of patients in professionals and medical knowledge make some approximation of an ideal speech situation more imperative than previously, the application of an instrumental concept of trust in the NHS makes such interactions less likely, as well as facilitating a divergence between instrumental and communicative rationality in healthcare provision.

Integrating dementia care in England and The Netherlands: Four comparative local case studies

The article presents a cross-national comparative study of the implementation of integrated dementia care at local level in England and The Netherlands. Four local case studies (Amsterdam Nieuw West, Leeds West, Maastricht, York) focus on the interaction between the respective national policies with local contexts and policy processes, in order to explain the variety of local outcomes regarding integrated dementia care. Localities are shown as entities with particular institutional contexts and histories (i.e. local configurations), which have specific impacts on processes of policy implementation within the respective national health and social care systems.

A surrealistic mega-analysis of redisorganization theories

BACKGROUND

We are sick and tired of being redisorganized.

OBJECTIVE

To systematically review the empirical evidence for organizational theories and repeated reorganizations.

METHODS

We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people's realities. We are sorry about this, but it is not our fault.

RESULTS

We discovered many reasons for repeated reorganizations, the most common being "no good reason". We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives.

CONCLUSIONS

We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.

A survey of the specialist public health workforce in the UK in 2003

OBJECTIVES

To identify the number and distribution of public health specialists in the UK.

STUDY DESIGN

Cross-sectional survey.

METHODS

Postal survey of UK members and fellows of the Faculty of Public Health and primary care trust directors of public health in England in October 2003.

RESULTS

Of 1993 individuals surveyed, 1566 (78%) responded, of whom 1331 reported working as consultants or specialists in public health in the UK. Of the 1331, 891 (67%) were on the General Medical Council Specialist Register, 53 (4%) were on the General Dental Council Register, and 92 (7%) were in the process of applying for the Voluntary Register; 295 (22%) did not appear to be on any professional register or in the process of applying to the Voluntary Register. This equated to a total UK rate of 14.1 per million 'service' public health. There was substantial variation by region from 9.3 per million population in Wales and the South West to 18.0 per million population in the West Midlands and 19.5 per million population in London. An increase of 218 (21%) additional consultants and specialists in public health across the UK would be required to bring other regions up to the level of the highest region.

CONCLUSIONS

This survey, although limited, being based on a survey of members and fellows of the Faculty of Public Health, shows that specialist public health is under capacity, is resourced in a highly variable manner, and needs to be built up to meet the challenges we face. A comprehensive workforce plan for public health is urgently needed.

Changing organisations: a study of the context and processes of mergers of health care providers in England

This paper presents findings from a study of the context and processes of provider mergers in the NHS in England. Mergers are an example of organisational restructuring, a key lever for change in the UK health care sector and elsewhere, although it is only one strategy for organisational change. The framework for the study is key themes from the organisational change literature: the complexity of the effects of change; the importance of context; and the role of organisational culture. The drivers for health care mergers and the evidence for these are analysed. Using documentary analysis and in-depth qualitative interviews with internal and external stakeholders, the first part of the paper reports on stated and unstated drivers in nine mergers. This provides the context for four in-depth case studies of the process of merger in the second and third years post-merger. Our study shows that the contexts of mergers, including drivers of change, are important. Merger is a process without clear boundaries, and this study shows problems persisting into the third year post-merger. Loss of management control and focus led to delays in service developments. Difficulties in the merger process included perceived differences in organisational culture and perceptions of 'takeover' which limited sharing of 'good practice' across newly merged organisations. Merger policy was based on simplistic assumptions about processes of organisational change that do not take into account the dynamic relationship between the organisation and its context and between the organisation and individuals within it. Understanding the process of merger better should lead to a more cautious approach to the likely gains, provide understanding of the problems that are likely in the period of change, and anticipate and avoid harmful consequences.

Evidence-based management in the NHS: is it possible?

The rise of evidence-based medicine and more recently evidence-based policy reflect the increasing importance of evidence as a basis for the organisation and delivery of health care. Evidence-based practice is central to the "modernisation" of health care in current UK policy. The latest manifestation of this process is the emergence of evidence-based management in health care. This paper examines the development of evidence-based approaches in health care and questions the appropriateness of such an approach to management. The problems inherent in applying the principles of EBP to management are explored and alternative apporoach based on the notion of craft is suggested as more practical and realistic.

Primary care trusts

Premature reorganisation, with mergers, may be harmful

Talking to health managers about change: heroes, villains and simplification

This paper presents contextual and empirical analyses of the pressures on senior health managers in the NHS through an examination of the documents produced by the NHS National Co-ordinating Centre for Service Delivery and Organisation on "Managing change". The result is a discussion and advocacy of the means through which "knowledge" with "knowing" might be brought together in the NHS to move it more towards an evidence-based approach to management.

Foucault on targets

This paper seeks to gain an insight into the behavior of a large NHS trust, in its attempt to meet a 90 percent patient access target, in a week long national audit in March 2003. Why did individuals act in dramatically different ways to their norm over this period. The work of Michel Foucault is used to explore these issues. The discourses of power, knowledge, discipline and governmentality are identified as key foucaudian themes that offer an alternative interpretation of how individuals behave in their place of work. The importance of the historical context of discourse within the NHS cannot be underestimated in shaping the behavior of individuals and groups today. Power and knowledge permeate NHS organizations through disciplinary practices and dressage. Governmentality seeks to maintain the status quo through disciplinary processes such as national healthcare targets. The natural response of NHS organizations is therefore, to seek order and conformity rather than disorder and conflict.

Modernizing the British National Health Service (NHS) -- some ideological and policy considerations: a commentary and application

The modernization of the British National Health Service, discussed by Peter Bradshaw in his paper, is having profound effects on nursing and patient care. The aim of this paper is to engage with the debate he has initiated in order to demonstrate its importance to nursing. The focus will be on key elements of the policy process not addressed by Peter Bradshaw as his emphasis was mainly on ideological concerns, but which nonetheless warrant consideration. These include the increasingly important role of evidence in policy making, and the role of nurses in the policy process. To this end four main themes are explored. First, specific comment is made on some of the points raised by Peter Bradshaw, in the context of the available evidence; secondly the role of evidence in the formulation and evaluation of policy is discussed; thirdly the policy process and nursing is examined; finally some tentative suggestions are made concerning the actions nurses and nurse managers can take to become more active in the health policy arena. The intention is to use Peter Bradshaw's work as a point of departure in examining further, some of the issues he highlights and to contribute to the debate.

Promoting nursing participation within primary care groups

This article describes the evaluation of a scheme to improve communication between primary care nurses and newly established primary care groups. Findings suggest that the successes of the scheme were in part attributable to the appointment of experienced practitioners to a facilitator/link nurse role and the sustained support of the scheme by the NHS community trust. The article concludes by suggesting that, in a time of constant change within primary care, innovations such as these contribute to the development of practitioner participation in the organization and delivery of primary care services.