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Perry C, Boaden RJ, Black GB, Clarke CS, Darley S, Ramsay AI, Shackley DC, Vindrola-Padros C, Fulop NJ. "Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration. Int J Health Policy Manag 2022; 11:2829-2841. [PMID: 35297232 PMCID: PMC10105206 DOI: 10.34172/ijhpm.2022.6389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/19/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The reconfiguration of specialist hospital services, with service provision concentrated in a reduced number of sites, is one example of major system change (MSC) for which there is evidence of improved patient outcomes. This paper explores the reconfiguration of specialist oesophago-gastric (OG) cancer surgery services in a large urban area of England (Greater Manchester, GM), with a focus on the role of history in this change process and how reconfiguration was achieved after previous failed attempts. METHODS This study draws on qualitative research from a mixed-methods evaluation of the reconfiguration of specialist cancer surgery services in GM. Forty-six interviews with relevant stakeholders were carried out, along with ~160 hours of observations at meetings and the acquisition of ~300 pertinent documents. Thematic analysis using deductive and inductive approaches was undertaken, guided by a framework of 'simple rules' for MSC. RESULTS Through an awareness of, and attention to, history, leaders developed a change process which took into account previous unsuccessful reconfiguration attempts, enabling them to reduce the impact of potentially challenging issues. Interviewees described attending to issues involving competition between provider sites, change leadership, engagement with stakeholders, and the need for a process of change resilient to challenge. CONCLUSION Recognition of, and response to, history, using a range of perspectives, enabled this reconfiguration. Particularly important was the way in which history influenced and informed other aspects of the change process and the influence of stakeholder power. This study provides further learning about MSC and the need for a range of perspectives to enable understanding. It shows how learning from history can be used to enable successful change.
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Affiliation(s)
- Catherine Perry
- Applied Research Collaboration Greater Manchester, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Ruth J. Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Georgia B. Black
- Department of Applied Health Research, University College London (UCL), London, UK
| | - Caroline S. Clarke
- UCL Research Department of Primary Care and Population Health, University College London (UCL), London, UK
| | - Sarah Darley
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Angus I.G. Ramsay
- Department of Applied Health Research, University College London (UCL), London, UK
| | - David C. Shackley
- Christie NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
| | | | - Naomi J. Fulop
- Department of Applied Health Research, University College London (UCL), London, UK
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2
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Baeza JI. The Role of the Policy Process on Health Service Reconfigurations: Evidence, Path Dependency and Framing Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration". Int J Health Policy Manag 2022; 12:7642. [PMID: 37579484 PMCID: PMC10125059 DOI: 10.34172/ijhpm.2022.7642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/22/2022] [Indexed: 08/16/2023] Open
Abstract
Historically healthcare services have largely developed on an incremental basis, with various piecemeal changes and some notable policy leaps that illustrate a punctuated equilibrium health policy process. More recently policy-makers have attempted, successfully and unsuccessfully, to reconfigure healthcare services to address perceived problems in the delivery of important services such as stroke, cancer, and trauma. Perry et al provide a welcome addition to research in this area by focusing on the importance of history in a reconfiguration of cancer services in Greater Manchester (GM). Perry et al analyse how and why this configuration was successful after several failed attempts in the past and in this commentary, I want to reflect on the explanatory role health policy analysis can contribute to studying the reconfiguration of healthcare services.
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Black GB, Wood VJ, Ramsay AIG, Vindrola-Padros C, Perry C, Clarke CS, Levermore C, Pritchard-Jones K, Bex A, Tran MGB, Shackley DC, Hines J, Mughal MM, Fulop NJ. Loss associated with subtractive health service change: The case of specialist cancer centralization in England. J Health Serv Res Policy 2022; 27:301-312. [PMID: 35471103 PMCID: PMC9548928 DOI: 10.1177/13558196221082585] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Major system change can be stressful for staff involved and can result in 'subtractive change' - that is, when a part of the work environment is removed or ceases to exist. Little is known about the response to loss of activity resulting from such changes. Our aim was to understand perceptions of loss in response to centralization of cancer services in England, where 12 sites offering specialist surgery were reduced to four, and to understand the impact of leadership and management on enabling or hampering coping strategies associated with that loss. METHODS We analysed 115 interviews with clinical, nursing and managerial staff from oesophago-gastric, prostate/bladder and renal cancer services in London and West Essex. In addition, we used 134 hours of observational data and analysis from over 100 documents to contextualize and to interpret the interview data. We performed a thematic analysis drawing on stress-coping theory and organizational change. RESULTS Staff perceived that, during centralization, sites were devalued as the sites lost surgical activity, skills and experienced teams. Staff members believed that there were long-term implications for this loss, such as in retaining high-calibre staff, attracting trainees and maintaining autonomy. Emotional repercussions for staff included perceived loss of status and motivation. To mitigate these losses, leaders in the centralization process put in place some instrumental measures, such as joint contracting, surgical skill development opportunities and trainee rotation. However, these measures were undermined by patchy implementation and negative impacts on some individuals (e.g. increased workload or travel time). Relatively little emotional support was perceived to be offered. Leaders sometimes characterized adverse emotional reactions to the centralization as resistance, to be overcome through persuasion and appeals to the success of the new system. CONCLUSIONS Large-scale reorganizations are likely to provoke a high degree of emotion and perceptions of loss. Resources to foster coping and resilience should be made available to all organizations within the system as they go through major change.
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Affiliation(s)
- Georgia B Black
- Principal Research Fellow, Department of Applied Health Research, 4919University College London, London, UK
| | - Victoria J Wood
- Research Associate, Department of Applied Health Research, 4919University College London, London, UK
| | - Angus I G Ramsay
- Senior Research Fellow, Department of Applied Health Research, 4919University College London, London, UK
| | - Cecilia Vindrola-Padros
- Senior Research Fellow, Department of Targeted Intervention, University College London, London, UK
| | - Catherine Perry
- Research Fellow, Applied Research Collaboration Greater Manchester/Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Caroline S Clarke
- Senior Research Fellow, Research Department of Primary Care & Population Health, University College London, London, UK
| | - Claire Levermore
- Executive Director of Operations, North Central London Cancer Alliance, 8964University College London Hospitals NHS Foundation Trust, London, UK
| | - Kathy Pritchard-Jones
- Professor of Paediatric Oncology, North Central London Cancer Alliance, University College London Hospitals NHS Foundation Trust, & University College London Partners, London, UK
| | - Axel Bex
- Department of Urology, 4965Royal Free London NHS Foundation Trust London, London, UK.,Consultant Clinical Lead Specialist Centre for Kidney Cancer, Division of Surgery and Interventional Science, University College London, London, UK
| | - Maxine G B Tran
- Senior Lecturer in Renal Cancer Surgery, Division of Surgery and Interventional Science, University College London, London, UK.,Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - David C Shackley
- Director & Medical Lead, Greater Manchester Cancer; Clinical Lead Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - John Hines
- Department of Urology, 4965Royal Free London NHS Foundation Trust London, London, UK.,Consultant Urological Surgeon and Urology Pathway Director, Division of Surgery and Interventional Science, University College London, London, UK
| | - Muntzer M Mughal
- Honorary Clinical Professor, Division of Surgery and Interventional Science, University College London, London, UK
| | - Naomi J Fulop
- Professor of Health Care Organisation and Management, Department of Applied Health Research, 4919University College London, London, UK
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4
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Vindrola-Padros C, Ramsay AIG, Black G, Barod R, Hines J, Mughal M, Shackley D, Fulop NJ. Inter-organisational collaboration enabling care delivery in a specialist cancer surgery provider network: A qualitative study. J Health Serv Res Policy 2022; 27:211-221. [PMID: 35130097 PMCID: PMC9277336 DOI: 10.1177/13558196211053954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective To explore the processes, challenges and strategies used to govern and
maintain inter-organisational collaboration between professionals in a
provider network in London, United Kingdom, which implemented major system
change focused on the centralisation of specialist cancer surgery. Methods We used a qualitative design involving interviews with stakeholders
(n = 117), non-participant observations
(n = 163) and documentary analysis (n
= 100). We drew on an existing model of collaboration in healthcare
organisations and expanded this framework by applying it to the analysis of
collaboration in the context of major system change. Results Network provider organisations established shared goals, maintained central
figures who could create and sustain collaboration, and promoted distributed
forms of leadership. Still, organisations continued to encounter barriers or
challenges in relation to developing opportunities for mutual
acquaintanceship across all professional groups; the active sharing of
knowledge, expertise and good practice across the network; the fostering of
trust; and creation of information exchange infrastructures fit for
collaborative purposes. Conclusion Collaborative relationships changed over time, becoming stronger
post-implementation in some areas, but continued to be negotiated where
resistance to the centralisation remained. Future research should explore
the sustainability of these relationships and further unpack how hierarchies
and power relationships shape inter-organisational collaboration.
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Affiliation(s)
- Cecilia Vindrola-Padros
- Senior Research Fellow, Department of Targeted Intervention, University College London, London, UK
| | - Angus I G Ramsay
- Senior Research Fellow, Department of Applied Health Research, University College London, London, UK
| | - Georgia Black
- Principal Research Fellow, Department of Applied Health Research, 4919University College London, London, UK
| | - Ravi Barod
- Consultant Urological Surgeon, Specialist Centre for Kidney Cancer, 4965Royal Free London NHS Foundation Trust, London, UK
| | - John Hines
- Consultant Urological Surgeon and London Cancer Urology Pathway Board Director, Department of Urology, 8964University College London Hospitals NHS Foundation Trust, London, UK
| | - Muntzer Mughal
- Consultant General & Upper Gastrointestinal Surgeon, 8964University College London Hospitals NHS Foundation Trust, London, UK
| | - David Shackley
- Medical Director, Greater Manchester Cancer and Manchester Academic Health Science Centre, Christie NHS Foundation Trust, Manchester, UK
| | - Naomi J Fulop
- Professor of Health Care Organisation and Management, Department of Applied Health Research, University College London, London, UK
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Fuller SS, Clarke E, Harding-Esch EM. Molecular chlamydia and gonorrhoea point of care tests implemented into routine practice: Systematic review and value proposition development. PLoS One 2021; 16:e0259593. [PMID: 34748579 PMCID: PMC8575247 DOI: 10.1371/journal.pone.0259593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Sexually Transmitted Infections, including Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), continue to be a global health problem. Increased access to point-of-care-tests (POCTs) could help detect infection and lead to appropriate management of cases and contacts, reducing transmission and development of reproductive health sequelae. Yet diagnostics with good clinical effectiveness evidence can fail to be implemented into routine care. Here we assess values beyond clinical effectiveness for molecular CT/NG POCTs implemented across diverse routine practice settings. METHODS We conducted a systematic review of peer-reviewed primary research and conference abstract publications in Medline and Embase reporting on molecular CT/NG POCT implementation in routine clinical practice until 16th February 2021. Results were extracted into EndNote software and initially screened by title and abstract by one author according to the inclusion and exclusion criteria. Articles that met the criteria, or were unclear, were included for full-text assessment by all authors. Results were synthesised to assess the tests against guidance criteria and develop a CT/NG POCT value proposition for multiple stakeholders and settings. FINDINGS The systematic review search returned 440 articles; 28 were included overall. The Cepheid CT/NG GeneXpert was the only molecular CT/NG POCT implemented and evaluated in routine practice. It did not fulfil all test guidance criteria, however, studies of test implementation showed multiple values for test use across various healthcare settings and locations. Our value proposition highlights that the majority of values are setting-specific. Sexual health services and outreach services have the least overlap, with General Practice and other non-sexual health specialist services serving as a "bridge" between the two. CONCLUSIONS Those wishing to improve CT/NG diagnosis should be supported to identify the values most relevant to their settings and context, and prioritise implementation of tests that are most closely aligned with those values.
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Affiliation(s)
- Sebastian S. Fuller
- Institute for Infection and Immunity, Applied Diagnostic Research and Evaluation Unit, St George’s University of London, London, United Kingdom
- Nuffield Department of Medicine, Health Systems Collaborative, University of Oxford, Headington, Oxford, United Kingdom
| | - Eleanor Clarke
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Emma M. Harding-Esch
- Institute for Infection and Immunity, Applied Diagnostic Research and Evaluation Unit, St George’s University of London, London, United Kingdom
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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6
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Milligan C, Berta W. Reimagining community relationships for organizational learning: a scoping review with implications for a learning health system. BMC Health Serv Res 2021; 21:603. [PMID: 34176468 PMCID: PMC8237504 DOI: 10.1186/s12913-021-06640-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 06/14/2021] [Indexed: 11/22/2022] Open
Abstract
Background Communities represent a highly relevant source of knowledge with regard to not only healthcare performance but also sociocultural context, yet their role in learning health systems has not been studied. Situating the learning health system as an organization, this paper explores the phenomenon of organizational learning from or with communities (defined as one of ‘the people,’ such as a town, a specific patient group or another group directly receiving a healthcare service). Methods We conducted a scoping review to determine what is known about organizational learning from or with communities that the organization serves, and to contribute to a more comprehensive evidence base for building and operating learning health systems. In March 2019, we systematically searched six academic databases and grey literature, applying no date limits, for English language materials that described organizational learning in relation to knowledge transfer between an organization and a community. Numerous variables were charted in Excel and synthesized using frequencies and thematic analysis. We updated this search in August 2020. Results In total, 42 documents were included in our analysis. We found a disproportionate emphasis on learning explicit knowledge from community rather than on tacit knowledge or learning in equal partnership with community. Our review also revealed inconsistently defined concepts, tenuously linked with their theoretical and empirical foundations. Our findings provide insight to understand the organization-community learning relationship, including motives and power differentials; types of knowledge to be learned; structures and processes for learning; and transformative learning outcomes. Conclusions Our review makes a singular contribution to organizational learning literatures by drawing from diverse research disciplines such as health services, business and education to map what is known about learning from or with community. Broadly speaking, learning health systems literature would benefit from additional research and theory-building within a sociological paradigm so as to establish key concepts and associations to understand the nature of learning with community, as well as the practices that make it happen. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06640-9.
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Affiliation(s)
- Crystal Milligan
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Ontario, M5T 3M6, Toronto, Canada.
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Ontario, M5T 3M6, Toronto, Canada
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Williams I, Harlock J, Robert G, Kimberly J, Mannion R. Is the end in sight? A study of how and why services are decommissioned in the English National Health Service. SOCIOLOGY OF HEALTH & ILLNESS 2021; 43:441-458. [PMID: 33636017 DOI: 10.1111/1467-9566.13234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/23/2020] [Accepted: 12/07/2020] [Indexed: 06/12/2023]
Abstract
The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.
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Affiliation(s)
- Iestyn Williams
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Jenny Harlock
- Warwick Medical School, University of Warwick, Warwick, UK
| | - Glenn Robert
- Florence Nightingale Faculty of Nursing & Midwifery & Palliative Care, King's College London, London, UK
| | - John Kimberly
- Wharton Business School, University of Pennsylvania, Philadelphia, PA, USA
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
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8
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Turner S, Niño N. Qualitative analysis of the coordination of major system change within the Colombian health system in response to COVID-19: study protocol. Implement Sci Commun 2020; 1:75. [PMID: 32939458 PMCID: PMC7490777 DOI: 10.1186/s43058-020-00063-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Coronavirus (COVID-19) is posing a major and unprecedented challenge to health service planning and delivery across health systems internationally. This nationally funded study is analysing the response of the Colombian health system to the COVID-19 pandemic, drawing on qualitative case studies of three local health systems within the country. The approach will be informed by the concept of 'major system change'-or coordinated change among a variety of healthcare organizations and other relevant stakeholders- to identify processes that both enable and inhibit adaptation of health services to the challenges presented by COVID-19. The study will collect information on capacity 'bottlenecks' as well as successful practices and forms of innovation that have emerged locally, which have the potential for being 'scaled up' across Colombia's health services. METHODS/DESIGN This qualitative study will be undertaken in two phases. In the first, up to 30 stakeholder interviews will be conducted to ascertain immediate challenges and opportunities for improvement in response to COVID-19 that can be shared in a timely way with health service leaders to inform health service planning. The stakeholders will include planning, provider and intermediary organizations within the health system at the national level. In the second, up to 60 further interviews will be conducted to develop in-depth case studies of three local health systems at the metropolitan area level within Colombia. The interview data will be supplemented with documentary analysis and, where feasible, non-participant observation of planning meetings. DISCUSSION The study's findings will aid evaluation of the relevance of the concept of major system change in a context of 'crisis' decision-making and contribute to international lessons on improving health systems' capacity to respond to COVID-19 and future pandemics. Study findings will be shared among various stakeholders in the Colombian healthcare system in a formative and timely way in order to inform healthcare planning in response to COVID-19 and future pandemics. Conducting the study at a time of COVID-19 raises a number of practical issues (including physical distancing and pressure on health services) which have been anticipated in the study design and research team's ways of working.
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Affiliation(s)
- Simon Turner
- School of Management, University of los Andes, Bogotá, Colombia
| | - Natalia Niño
- School of Management, University of los Andes, Bogotá, Colombia
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9
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Stewart E, Greer SL, Ercia A, Donnelly PD. Transforming health care: the policy and politics of service reconfiguration in the UK's four health systems. HEALTH ECONOMICS, POLICY, AND LAW 2020; 15:289-307. [PMID: 30975243 PMCID: PMC7525102 DOI: 10.1017/s1744133119000148] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/23/2018] [Accepted: 11/29/2018] [Indexed: 11/24/2022]
Abstract
Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used 'sticks' and 'sermons' to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.
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Affiliation(s)
- Ellen Stewart
- Centre for Biomedicine, Self & Society, Usher Institute, Old Medical School, University of Edinburgh, Teviot Place, EdinburghEH8 9AG, UK
| | - Scott L. Greer
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, Michigan48109-2029, USA
| | - Angelo Ercia
- Centre for Health Informatics, The University of Manchester, Vaughan House, Portsmouth Street, ManchesterM13 9GB, UK
| | - Peter D. Donnelly
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Jones L, Fraser A, Stewart E. Exploring the neglected and hidden dimensions of large-scale healthcare change. SOCIOLOGY OF HEALTH & ILLNESS 2019; 41:1221-1235. [PMID: 31099047 DOI: 10.1111/1467-9566.12923] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Forms of large-scale change, such as the regiona l re-distribution of clinical services, are an enduring reform orthodoxy in health systems of high-income countries. The topic is of relevance and importance to medical sociology because of the way that large-scale change significantly disrupts and transforms therapeutic landscapes, relationships and practices. In this paper we review the literature on large-scale change. We find that the literature is dominated by competing forms of knowledge, such as health services research, and show how sociology can contribute new and critical perspectives and insights on what is for many people a troubling issue.
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Affiliation(s)
- Lorelei Jones
- School of Health Sciences, University of Bangor, Bangor, UK
| | - Alec Fraser
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ellen Stewart
- Centre for Biomedicine, Self and Society, University of Edinburgh, Edinburgh, UK
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11
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Fraser A, Baeza J, Boaz A, Ferlie E. Biopolitics, space and hospital reconfiguration. Soc Sci Med 2019; 230:111-121. [PMID: 31009877 DOI: 10.1016/j.socscimed.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/27/2019] [Accepted: 04/10/2019] [Indexed: 11/19/2022]
Abstract
Major service change in healthcare - whereby the distribution of services is reconfigured at a local or regional level - is often a contested, political and poorly understood set of processes. This paper contributes to the theoretical understanding of major service change by demonstrating the utility of interpreting health service reconfiguration as a biopolitical intervention. Such an approach orients the analytical focus towards an exploration of the spatial and the population - crucial factors in major service change. Drawing on a qualitative study from 2011-12 of major service change in the English NHS combining documentary analyses of historically relevant policy papers and contemporary policy documentation (n = 125) with semi-structured interviews (n = 20) we highlight how a particular 'geography of stroke' in London was created building upon multiple types of knowledge: medical, epidemiological, economic, demographic, managerial and organisational. These informed particular spatial practices of government providing legitimation for the significant political upheaval that accompanies NHS service reconfiguration by problematizing existing variation in outcomes and making these visible. We suggest that major service change may be analysed as a 'practice of security' - a way of redefining a case, conceiving of risks and dangers, and averting potential crises in the interests of the population.
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Affiliation(s)
- Alec Fraser
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
| | - Juan Baeza
- Health Policy, King's Business School, King's College London, Bush House, 30 Aldwych, London, WC2B 4BG, United Kingdom.
| | - Annette Boaz
- Health Care Research, Faculty of Health, Social Care and Education, St. George's, University of London & Kingston University, Hunter Wing, Cranmer Terrace, London, SW17 ORE, United Kingdom.
| | - Ewan Ferlie
- Public Service Management, King's Business School, King's College London, Bush House, 30 Aldwych, London, WC2B 4BG, United Kingdom.
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12
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Fulop NJ, Ramsay AIG, Hunter RM, McKevitt C, Perry C, Turner SJ, Boaden R, Papachristou I, Rudd AG, Tyrrell PJ, Wolfe CDA, Morris S. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background
Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.
Objective
To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.
Design
Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.
Results
Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.
Limitations
The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.
Conclusions
Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Angus IG Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Christopher McKevitt
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Catherine Perry
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Simon J Turner
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Ruth Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Anthony G Rudd
- Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Pippa J Tyrrell
- Stroke and Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Charles DA Wolfe
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
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13
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Waring J, Bishop S, Clarke J, Exworthy M, Fulop NJ, Hartley J, Ramsay AIG. Healthcare leadership with political astuteness (HeLPA): a qualitative study of how service leaders understand and mediate the informal 'power and politics' of major health system change. BMC Health Serv Res 2018; 18:918. [PMID: 30509270 PMCID: PMC6276206 DOI: 10.1186/s12913-018-3728-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The implementation of strategic health system change is often complicated by the informal politics and power of health systems, such as competing interests and resistant groups. Evidence from other industries shows that strategic leaders need to be aware of and manage such 'organisational politics' when implementing change, which involves developing and using forms of political 'skill', 'savvy' or 'astuteness'. The purpose of this study is to investigate the acquisition, use and contribution of political 'astuteness' in the implementation of strategic health system change. METHODS The qualitative study comprises four linked work packages. First, we will complete a systematic 'review of reviews' on the topic of political skill and astuteness, and related social science concepts, which will be used to then review the existing health services research literature to identify exemplars of political astuteness in health care systems. Second, we will carry out semi-structured biographical interviews with regional and national service leaders, and recent recipients of leadership training, to understand their acquisition and use of political astuteness. Third, we will carry out in-depth ethnographic research looking at the utilisation and contribution of political astuteness in three contemporary examples of strategic health system change. Finally, we will explore and discuss the study findings through a series of co-production workshops to inform the development and testing of new learning resources and materials for future NHS leaders. DISCUSSION The research will produce evidence about the relatively under-researched contribution that political skill and astuteness makes in the implementation of strategic health system change. It intends to offer new understanding of these skills and capabilities that takes greater account of the wider social, cultural organisational landscape, and offers tangible lessons and case examples for service leaders. The study will inform future learning materials and processes, and create spaces for future leaders to reflect upon their political astuteness in a constructive and development way. TRIAL REGISTRATION Researchregistery4020 [23rd April 2018].
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Affiliation(s)
- Justin Waring
- Nottingham University Business School, Jubilee Campus, University of Nottingham, Nottingham, NG8 1BB UK
| | - Simon Bishop
- Nottingham University Business School, Jubilee Campus, University of Nottingham, Nottingham, NG8 1BB UK
| | - Jenelle Clarke
- Nottingham University Business School, Jubilee Campus, University of Nottingham, Nottingham, NG8 1BB UK
| | - Mark Exworthy
- Health Service Management Centre, Park House, University of Birmingham, Birmingham, B15 2RT UK
| | - Naomi J. Fulop
- Department of Applied Health Research, University College London, 1-19 Torrington Place, Fitzrovia, London, WC1E 7HB UK
| | - Jean Hartley
- Open University Business School, The Open University, Kents Hill, Milton Keynes, MK7 6AA UK
| | - Angus I. G. Ramsay
- Department of Applied Health Research, University College London, 1-19 Torrington Place, Fitzrovia, London, WC1E 7HB UK
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14
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Hanney SR, González-Block MA. 'Knowledge for better health' revisited - the increasing significance of health research systems: a review by departing Editors-in-Chief. Health Res Policy Syst 2017; 15:81. [PMID: 28965493 PMCID: PMC5623979 DOI: 10.1186/s12961-017-0248-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/06/2017] [Indexed: 01/22/2023] Open
Abstract
How can nations organise research investments to obtain the best bundle of knowledge and the maximum level of improved health, spread as equitably as possible? This question was the central focus of a major initiative from WHO led by Prof Tikki Pang, which resulted in a range of developments, including the publication of a conceptual framework for national health research systems - Knowledge for better health - in 2003, and in the founding of the journal Health Research Policy and Systems (HARPS). As Editors-in-Chief of the journal since 2006, we mark our retirement by tracking both the progress of the journal and the development of national health research systems. HARPS has maintained its focus on a range of central themes that are key components of a national health research system in any country. These include building capacity to conduct and use health research, identifying appropriate priorities, securing funds and allocating them accountably, producing scientifically valid research outputs, promoting the use of research in polices and practice in order to improve health, and monitoring and evaluating the health research system. Some of the themes covered in HARPS are now receiving increased attention and, for example, with the assessment of research impact and development of knowledge translation platforms, the journal has covered their progress throughout that expansion of interest. In addition, there is increasing recognition of new imperatives, including the importance of promoting gender equality in health research if benefits are to be maximised. In this Editorial, we outline some of the diverse and developing perspectives considered within each theme, as well as considering how they are held together by the growing desire to build effective health research systems in all countries.From 2003 until mid-June 2017, HARPS published 590 articles on the above and related themes, with authors being located in 76 countries. We present quantitative data tracing the journal's growth and the increasing external recognition of its role. We thank the many colleagues who have kindly contributed to the journal's success, and finish on an exciting note by welcoming the new Editors-in-Chief who will take HARPS forward.
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Affiliation(s)
- Stephen R. Hanney
- Health Economics Research Group, Institute of Environment, Health and Societies, Brunel University London, Kingston Lane, Uxbridge, UB8 3PH United Kingdom
| | - Miguel A. González-Block
- Universidad Anáhuac, Av. Universidad Anáhuac 46, Lomas Anáhuac, 52786 Huixquilucan Mexico City, Mexico
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