- 0116 252 3207
Graham Martin
University of Leicester, Health Sciences, Faculty Member
- As far as possible within the terms of publishers' copyright/licence agreements, I have made my sole- and lead-author... moreAs far as possible within the terms of publishers' copyright/licence agreements, I have made my sole- and lead-authored papers available for download on this site, in their revised form following peer review. If you have electronic access, you can also get the published versions via the journals' websites - links are provided. If you don't have electronic access to these journals, and for other papers which I've authored or co-authored but which aren't available for download here, please e-mail me and I'll be happy to send you a copy.edit
OBJECTIVES: We explore the role of consumer trustees in decision-making as community health centers (CHCs) work to navigate the tension between pursuing their mission to provide primary care to all regardless of ability to pay and... more
OBJECTIVES: We explore the role of consumer trustees in decision-making as community health centers (CHCs) work to navigate the tension between pursuing their mission to provide primary care to all regardless of ability to pay and maintaining their limited finances.
METHODS: We interviewed 30 trustees from 16 CHCs in 14 different states, asking extensively about decision-making processes at their CHC related to services and finances, as well as perceived advantages and disadvantages of consumer governance.
RESULTS: Respondents described mission-dominant, margin-dominant, and balanced decision-making philosophies, and different decision-making pathways for service provision and finances. Consumer trustees were lauded for their role in informing the board of service quality and community needs, but criticized for being professionally unskilled and exhibiting a lack of objective decision-making.
CONCLUSIONS: While CHC boards do play a role in navigating the tension between mission and margin, executive directors and staff appear to be more influential.
METHODS: We interviewed 30 trustees from 16 CHCs in 14 different states, asking extensively about decision-making processes at their CHC related to services and finances, as well as perceived advantages and disadvantages of consumer governance.
RESULTS: Respondents described mission-dominant, margin-dominant, and balanced decision-making philosophies, and different decision-making pathways for service provision and finances. Consumer trustees were lauded for their role in informing the board of service quality and community needs, but criticized for being professionally unskilled and exhibiting a lack of objective decision-making.
CONCLUSIONS: While CHC boards do play a role in navigating the tension between mission and margin, executive directors and staff appear to be more influential.
Research Interests:
Research Interests:
Background: Walkrounds, introduced as Leadership (or Executive) WalkRounds,™ are a widely advocated model for increasing leadership engagement in patient safety to improve safety culture, but evidence for their effectiveness is mixed. In... more
Background: Walkrounds, introduced as Leadership (or Executive) WalkRounds,™ are a widely advocated model for increasing leadership engagement in patient safety to improve safety culture, but evidence for their effectiveness is mixed. In the English National Health Service (NHS), hospitals have been strongly encouraged to make use of methods closely based on the walkrounds approach. A study was conducted to explore how walkrounds are used in practice and to identify variations in implementation that might mediate their impact on safety and culture.
Methods: The data, collected from 82 semistructured interviews in the English NHS, were drawn from two components of a wider study of culture and behavior around quality and safety in the English system. Analysis was based on the constant comparative method.
Findings: Our analysis highlights how local, pragmatic adjustments to the walkrounds approach could radically alter its character and the way in which it is received by those at the front line. The modification and expansion of walkrounds to increase the scope of knowledge produced could increase the value that executives draw from them. However, it risks replacing the main objectives of walkrounds—specific, actionable knowledge about safety issues, and a more positive safety culture and relationship between ward and board—with a form of surveillance that could alienate frontline staff and produce fallible insights.
Conclusion: The study’s findings suggest some plausible explanations for the mixed evidence for walkrounds’ effectiveness in creating a safety culture. On a practical level, they point to critical questions that executives must ask themselves in practicing interventions of this nature to ensure that adaptations align rather than conflict with the intervention’s model of change.
Methods: The data, collected from 82 semistructured interviews in the English NHS, were drawn from two components of a wider study of culture and behavior around quality and safety in the English system. Analysis was based on the constant comparative method.
Findings: Our analysis highlights how local, pragmatic adjustments to the walkrounds approach could radically alter its character and the way in which it is received by those at the front line. The modification and expansion of walkrounds to increase the scope of knowledge produced could increase the value that executives draw from them. However, it risks replacing the main objectives of walkrounds—specific, actionable knowledge about safety issues, and a more positive safety culture and relationship between ward and board—with a form of surveillance that could alienate frontline staff and produce fallible insights.
Conclusion: The study’s findings suggest some plausible explanations for the mixed evidence for walkrounds’ effectiveness in creating a safety culture. On a practical level, they point to critical questions that executives must ask themselves in practicing interventions of this nature to ensure that adaptations align rather than conflict with the intervention’s model of change.
Research Interests:
Partnership is a prominent approach to delivering healthcare globally, with advocates arguing that partnership has distinctive advantages over alternatives such as hierarchies or markets. There is much debate as to whether partnerships... more
Partnership is a prominent approach to delivering healthcare globally, with advocates arguing that partnership has distinctive advantages over alternatives such as hierarchies or markets. There is much debate as to whether partnerships represent a distinctive mode of coordination in practice, however. Furthermore, despite evidence from diverse settings of the challenges of putting partnerships into practice, there has been little cross-pollination between literature from different fields. We bring together existing literature and two partnership case studies in the contrasting contexts of the UK National Health Service and an internationally-funded health intervention in Cambodia. The case studies were conducted between 2005 and 2008.
Based on our synthesis of the literature, we propose an analytical distinction between instrumental and transformative partnerships, arguing that it is transformative partnerships that can deliver the unique advantages set out in theory. Comparative analysis of the cases illustrates that although both were able to achieve some valuable successes, they fell short of realising their transformative potential. We identify five common issues that impeded or facilitated transformative partnership-working, at micro, meso- and macro-levels: starting conditions; programme set-up; funding asymmetries and interdependence; accountability mechanisms; and relationships and distance from the field. Through systematic comparison we offer a more nuanced understanding of how programmes themselves create particular architectures for partnership, how underlying globalised institutional logics of managerialism promote instrumental partnerships, and how local-level, interpersonal relationships may help to overcome barriers to partnership’s transformative potential.
Based on our synthesis of the literature, we propose an analytical distinction between instrumental and transformative partnerships, arguing that it is transformative partnerships that can deliver the unique advantages set out in theory. Comparative analysis of the cases illustrates that although both were able to achieve some valuable successes, they fell short of realising their transformative potential. We identify five common issues that impeded or facilitated transformative partnership-working, at micro, meso- and macro-levels: starting conditions; programme set-up; funding asymmetries and interdependence; accountability mechanisms; and relationships and distance from the field. Through systematic comparison we offer a more nuanced understanding of how programmes themselves create particular architectures for partnership, how underlying globalised institutional logics of managerialism promote instrumental partnerships, and how local-level, interpersonal relationships may help to overcome barriers to partnership’s transformative potential.
Research Interests:
Research Interests:
In healthcare, translating evidence into changed practice remains challenging. Novel interventions are being used to address these challenges, including the use of ‘knowledge brokers’. But how sustainable these roles might be, and the... more
In healthcare, translating evidence into changed practice remains challenging. Novel interventions are being used to address these challenges, including the use of ‘knowledge brokers’. But how sustainable these roles might be, and the consequences for the individual of enacting such roles, are unknown. We explore these questions by drawing on qualitative data from case studies of full-time roles in a research-practice collaboration. We suggest that structural issues around professional boundaries, organisational norms and career pathways may make such roles difficult to sustain in the long-term, but highlight interventions that might improve their feasibility.
Research Interests: Communication, Knowledge Management, Organizational Change, Intercultural Management, Health Care Administration, and 15 moreHealth Care, Implementation Science, Health Care Management, Healthcare, Change agents, Middle Management, Case Study, Readiness for Change, Multicultural, Managing Change, Involvement, Change Implementation, Change Resistance, Coping With Change, and Change Factors
Objectives: We aimed to explore the views of strategic-level stakeholders on leadership for quality and safety in the NHS. Methods: We interviewed 107 stakeholders with close involvement with quality and safety as professionals,... more
Objectives: We aimed to explore the views of strategic-level stakeholders on leadership for quality and safety in the NHS.
Methods: We interviewed 107 stakeholders with close involvement with quality and safety as professionals, managers, policy makers or commentators. Analysis was based on the constant comparative method.
Results: Participants identified the crucial role of leadership in ensuring safe, high quality care. Consistent with the academic literature, participants distinguished between traditional hierarchical “concentrated” leadership associated with particular positions, and distributed leadership involving those with particular skills and abilities across multiple institutional levels. They clearly and explicitly saw a role for distributed leadership, emphasising that all staff had responsibility for leading on patient safety and quality. They described the particular value of leadership coalitions between managers and clinicians. However, concern was expressed that distributed leadership could mean confusion about who was in charge, and that at national levelit risked creating a vacuum of authority, mixed messages, and conflicting expectations and demands. Participants also argued that at organisational level, hierarchically based leadership was needed to complement distributed leadership at organisational level, not least to provide focus, practical support and expertise, and managerial clout.
Conclusions: Strategic-level stakeholders see the most effective form of leadership for quality and safety as one that blends distributed and concentrated leadership. Policy and academic prescriptions about leadership may benefit from the sophisticated and pragmatic know-how of insiders who work in organisations that remain permeated by traditional structures, cleavages and power relationships.
Methods: We interviewed 107 stakeholders with close involvement with quality and safety as professionals, managers, policy makers or commentators. Analysis was based on the constant comparative method.
Results: Participants identified the crucial role of leadership in ensuring safe, high quality care. Consistent with the academic literature, participants distinguished between traditional hierarchical “concentrated” leadership associated with particular positions, and distributed leadership involving those with particular skills and abilities across multiple institutional levels. They clearly and explicitly saw a role for distributed leadership, emphasising that all staff had responsibility for leading on patient safety and quality. They described the particular value of leadership coalitions between managers and clinicians. However, concern was expressed that distributed leadership could mean confusion about who was in charge, and that at national levelit risked creating a vacuum of authority, mixed messages, and conflicting expectations and demands. Participants also argued that at organisational level, hierarchically based leadership was needed to complement distributed leadership at organisational level, not least to provide focus, practical support and expertise, and managerial clout.
Conclusions: Strategic-level stakeholders see the most effective form of leadership for quality and safety as one that blends distributed and concentrated leadership. Policy and academic prescriptions about leadership may benefit from the sophisticated and pragmatic know-how of insiders who work in organisations that remain permeated by traditional structures, cleavages and power relationships.
Research Interests: Organizational Change, International Business, Leadership, International Trade, Health Care Administration, and 11 moreSustainable Development, Africa, Strategic Management, Global Leadership, Health Services Research, Health Policy, Quality of Healthcare Services, Healthcare, Healthcare Administration, Organizational Development, and International Management
The need for organizational innovation as a means of improving health-care quality and containing costs is widely recognized, but while a growing body of research has improved knowledge of implementation, very little has considered the... more
The need for organizational innovation as a means of improving health-care quality and containing costs is widely recognized, but while a growing body of research has improved knowledge of implementation, very little has considered the challenges involved in sustaining change – especially organizational change led ‘bottom-up’ by frontline clinicians. This study addresses this lacuna, taking a longitudinal, qualitative case-study approach to understanding the paths to sustainability of four organizational innovations. It highlights the importance of the interaction between organizational context, nature of the innovation and strategies deployed in achieving sustainability. It discusses how positional influence of service leads, complexity of innovation, networks of support, embedding in existing systems, and proactive responses to changing circumstances can interact to sustain change. In the absence of cast-iron evidence of effectiveness, wider notions of value may be successfully invoked to sustain innovation. Sustainability requires continuing effort through time, rather than representing a final state to be achieved. Our study offers new insights into the process of sustainability of organizational change, and elucidates the complement of strategies needed to make bottom-up change last in challenging contexts replete with competing priorities.
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Introduction Patient and public involvement in healthcare planning, service development and health-related research has received significant attention. However, evidence about the role of patient involvement in quality improvement work... more
Introduction
Patient and public involvement in healthcare planning, service development and health-related research has received significant attention. However, evidence about the role of patient involvement in quality improvement work is more limited. We aimed to characterize patient involvement in three improvement projects and to identify strengths and weaknesses of contrasting approaches.
Methods
Three case study quality improvement projects were purposively sampled from a broader programme. We used an ethnographic approach involving 126 in-depth interviews, 12 weeks of non-participant observations and documentary analysis. Data analysis was based on the constant comparative method.
Results
The three projects differed in the ways they involved patients in their quality improvement work, including their rationales for including patients. We characterized three very different models of patient involvement, which were each influenced by project context. Patients played distinctive roles across the three projects, acting in some cases as intermediaries between the wider patient community and clinicians, and sometimes undertaking persuasive work to convince clinicians of the need for change. We identified specific strategies that can be used to help ensure that patient involvement works most effectively and that the enthusiasm of patients to make a difference is not dissipated.
Conclusion
Patient involvement in quality improvement work needs careful management to realize its full potential.
Patient and public involvement in healthcare planning, service development and health-related research has received significant attention. However, evidence about the role of patient involvement in quality improvement work is more limited. We aimed to characterize patient involvement in three improvement projects and to identify strengths and weaknesses of contrasting approaches.
Methods
Three case study quality improvement projects were purposively sampled from a broader programme. We used an ethnographic approach involving 126 in-depth interviews, 12 weeks of non-participant observations and documentary analysis. Data analysis was based on the constant comparative method.
Results
The three projects differed in the ways they involved patients in their quality improvement work, including their rationales for including patients. We characterized three very different models of patient involvement, which were each influenced by project context. Patients played distinctive roles across the three projects, acting in some cases as intermediaries between the wider patient community and clinicians, and sometimes undertaking persuasive work to convince clinicians of the need for change. We identified specific strategies that can be used to help ensure that patient involvement works most effectively and that the enthusiasm of patients to make a difference is not dissipated.
Conclusion
Patient involvement in quality improvement work needs careful management to realize its full potential.
Research Interests:
In many developed-world countries, there have been efforts to increase the ‘leadership capacity’ of healthcare professionals, particularly lower-status staff without formal managerial power. Creating frontline ‘leaders’ is seen as a... more
In many developed-world countries, there have been efforts to increase the ‘leadership capacity’ of healthcare professionals, particularly lower-status staff without formal managerial power. Creating frontline ‘leaders’ is seen as a means of improving the quality of healthcare, but such efforts face considerable challenges in practice. This paper reports on a qualitative, interview-based study of 23 staff in two UK operating theatre departments, mostly nurses by professional background, who were given formal leadership responsibilities by their hospitals and redesignated as ‘team leaders’ and ‘theatre co-ordinators’. While participants were familiar with leadership theory and could offer clear accounts of good leadership in practice, they were often limited in their ability to enact their leadership roles. Professional and managerial hierarchies constrained participants’ leadership capacity, and consequently the exercise of leadership rested on alignment with managerial relationships and mandates. The findings highlight difficulties with accounts of leadership as something to be distributed across organisations; in healthcare organisations, established institutional structures and norms render this approach problematic. Rather, if fostering leadership capacity is to have the transformational effect that policymakers desire, it may need to be accompanied by other, wider changes that attend to institutional, organisational and professional context.
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"Background: Peer review offers a promising way of promoting improvement in health systems, but the optimal model is not yet clear. We aimed to identify lessons from the facilitated reciprocal peer to peer review (RP2PR) methodology used... more
"Background: Peer review offers a promising way of promoting improvement in health systems, but the optimal model is not yet clear. We aimed to identify lessons from the facilitated reciprocal peer to peer review (RP2PR) methodology used in the Improving Lung Cancer Outcomes Project (ILCOP).
Methods: Thirty paired English NHS trusts participated in facilitated reciprocal site visits. An ethnographic study of six pairs was undertaken involving non-participant observations of site visits and ILCOP programme activities, documentary collection, and 46 in-depth interviews. Analysis was based on the constant comparative method.
Results: RP2PR was generally a positive experience for participants. It provided stimulus and direction for improvement, including the production of quality improvement plans. Five key features were identified as important in the ILCOP model: the core team; peers and pairing methods; structure of discussion sessions; the facilitator role; and credibility of the process. All but one of the participating teams produced quality improvement plans, but implementation was challenging for some. Support from the ILCOP core team and managerial commitment from participating sites was essential. RP2PR appears to be optimised when: it is well organised; a safe environment for learning is created; credibility is maximised; and implementation and impact are supported.
Discussion: RP2PR may have a valuable role in improvement alongside other more established methods. Facilitated reciprocal peer review is seen as credible and legitimate by lung cancer teams and can act as a powerful stimulus to produce focused quality improvement plans and to support implementation. Our findings have identified how RP2PR may be optimised to provide a constructive, open space for identifying opportunities for improvement and solutions. Challenges to ensuring follow through were identified."
Methods: Thirty paired English NHS trusts participated in facilitated reciprocal site visits. An ethnographic study of six pairs was undertaken involving non-participant observations of site visits and ILCOP programme activities, documentary collection, and 46 in-depth interviews. Analysis was based on the constant comparative method.
Results: RP2PR was generally a positive experience for participants. It provided stimulus and direction for improvement, including the production of quality improvement plans. Five key features were identified as important in the ILCOP model: the core team; peers and pairing methods; structure of discussion sessions; the facilitator role; and credibility of the process. All but one of the participating teams produced quality improvement plans, but implementation was challenging for some. Support from the ILCOP core team and managerial commitment from participating sites was essential. RP2PR appears to be optimised when: it is well organised; a safe environment for learning is created; credibility is maximised; and implementation and impact are supported.
Discussion: RP2PR may have a valuable role in improvement alongside other more established methods. Facilitated reciprocal peer review is seen as credible and legitimate by lung cancer teams and can act as a powerful stimulus to produce focused quality improvement plans and to support implementation. Our findings have identified how RP2PR may be optimised to provide a constructive, open space for identifying opportunities for improvement and solutions. Challenges to ensuring follow through were identified."
Research Interests:
Background: Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the... more
Background: Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature.
Methods: The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.
Results: The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.
Discussion: Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.
Methods: The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.
Results: The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.
Discussion: Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.
Research Interests:
Purpose: CLAHRCs are a new UK initiative to promote collaboration between universities and healthcare organisations in carrying out and applying the findings of applied health research. But they face significant, institutionalised... more
Purpose: CLAHRCs are a new UK initiative to promote collaboration between universities and healthcare organisations in carrying out and applying the findings of applied health research. But they face significant, institutionalised barriers to their success. This paper analyses these challenges and discusses prospects for overcoming them.
Design: We draw on in-depth qualitative interview data from the first round of an ongoing evaluation of one CLAHRC to understand the views of different stakeholders on its progress so far, challenges faced, and emergent solutions.
Findings: The breadth of CLAHRCs’ missions seems crucial to mobilise the diverse stakeholders needed to succeed, but also produces disagreement about what the prime goal of the Collaborations should be. A process of consensus building is necessary to instil a common vision among CLAHRC members, but deep-seated institutional divisions continue to orient them in divergent directions, which may need to be overcome through other means.
Originality/value: Our analysis suggests some of the key means by which those involved in joint enterprises such as CLAHRCs can achieve consensus and action towards a current goal, and offers recommendations for those involved in their design, commissioning and performance management.
Design: We draw on in-depth qualitative interview data from the first round of an ongoing evaluation of one CLAHRC to understand the views of different stakeholders on its progress so far, challenges faced, and emergent solutions.
Findings: The breadth of CLAHRCs’ missions seems crucial to mobilise the diverse stakeholders needed to succeed, but also produces disagreement about what the prime goal of the Collaborations should be. A process of consensus building is necessary to instil a common vision among CLAHRC members, but deep-seated institutional divisions continue to orient them in divergent directions, which may need to be overcome through other means.
Originality/value: Our analysis suggests some of the key means by which those involved in joint enterprises such as CLAHRCs can achieve consensus and action towards a current goal, and offers recommendations for those involved in their design, commissioning and performance management.
Research Interests:
Participatory forums, in which lay citizens or users of public services contribute to the governance of public services, have proliferated in recent years. In debates about the quality and influence of such processes, there has been... more
Participatory forums, in which lay citizens or users of public services contribute to the governance of public services, have proliferated in recent years. In debates about the quality and influence of such processes, there has been increasing recognition of the importance of emotional as well as rational deliberation, and criticism of the way in which the structures imposed on such forums can exclude certain participants and discourses. This paper presents a study of one such forum, convened by an independent organisation to influence the development and management of state services, and governed by self-determined norms of participation and conduct. It highlights both the potential of such public deliberations beyond the state to generate novel outputs that influence public-service provision, but also the way in which such forums, and their lack of imposed rules and norms of deliberation, can themselves work to exclude certain participants and discourses.
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This paper considers the rise of ‘leadership’ in discourses relating to the British health service, and the application of the term to increasingly heterogeneous actors. Analysing interviews with NHS chief executives from the late 1990s,... more
This paper considers the rise of ‘leadership’ in discourses relating to the British health service, and the application of the term to increasingly heterogeneous actors. Analysing interviews with NHS chief executives from the late 1990s, and key policy documents published since, the authors highlight how leadership has become a term of choice among policymakers, with positive cultural valences which previously predominant terms such as ‘management’ now lack. They note in particular how leadership is increasingly conferred not only on those in positions of formal power but on frontline clinicians, patients and even the public, and how not just the implementation but the design of policy is now constructed as being led by these groups. Such constructions of the distribution of power in the health service, however, contradict the picture drawn by academic work. The authors suggest, therefore, that part of the purpose of leadership discourse is to align the subjectivities of health-service stakeholders with policy intentions, making their implementation not just everyone’s responsibility, but part of everyone’s sense of self. Given the realities of organizational life for many of the subjects of leadership discourse, however, the extent to which leadership retains its current positive associations and ubiquity remains to be seen.
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The limited extent to which research evidence is utilised in healthcare and other public services is widely acknowledged. The UK government has attempted to address this gap by funding nine Collaborations for Leadership in Applied Health... more
The limited extent to which research evidence is utilised in healthcare and other public services is widely acknowledged. The UK government has attempted to address this gap by funding nine Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). CLAHRCs aim to carry out health research, implement research findings in local healthcare organisations, and build capacity across organisations for generating and using evidence. This wide-ranging brief requires multifaceted approaches; assessing CLAHRCs’ success thus poses challenges for evaluation. This paper discusses these challenges in relation to seven CLAHRC evaluations, eliciting implications and suggestions for others evaluating similarly complex interventions with diverse objectives.
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Objectives: There have been calls for greater exchange between research and practice in healthcare policy and management, but little empirical research on what commissioners of research and researchers themselves consider appropriate,... more
Objectives: There have been calls for greater exchange between research and practice in healthcare policy and management, but little empirical research on what commissioners of research and researchers themselves consider appropriate, good-quality research knowledge. This paper addresses this gap, considering the views of commissioners and producers of policy and management research in healthcare and other fields.
Methods: Qualitative semi-structured interviews with 18 commissioners and producers of research, in central government, the NHS and other commissioning organisations, and in universities and independent-sector providers.
Results: Commissioners and producers agreed that research often fails to fulfil policymakers’ and managers’ needs, and that greater interaction is required to improve this relationship. However, they offered differing accounts of the nature of research knowledge (as a ‘product’ or a ‘mindset’), and of what constitutes value, validity and originality in research, reflecting the differing priorities and pressures faced by the two groups.
Conclusions: Efforts to promote greater interaction between research, policy and practice, and more critical, reflexive engagement between policymakers, managers and researchers, are likely to face significant obstacles given these competing constructions of research knowledge and their reinforcement by divergent priorities.
Methods: Qualitative semi-structured interviews with 18 commissioners and producers of research, in central government, the NHS and other commissioning organisations, and in universities and independent-sector providers.
Results: Commissioners and producers agreed that research often fails to fulfil policymakers’ and managers’ needs, and that greater interaction is required to improve this relationship. However, they offered differing accounts of the nature of research knowledge (as a ‘product’ or a ‘mindset’), and of what constitutes value, validity and originality in research, reflecting the differing priorities and pressures faced by the two groups.
Conclusions: Efforts to promote greater interaction between research, policy and practice, and more critical, reflexive engagement between policymakers, managers and researchers, are likely to face significant obstacles given these competing constructions of research knowledge and their reinforcement by divergent priorities.
Research Interests:
Current health-care policy emphasises the need for more collaborative, team-based approaches to providing care, and for a greater voice for service users in the management and delivery of care. Increasingly, policy encourages... more
Current health-care policy emphasises the need for more collaborative, team-based approaches to providing care, and for a greater voice for service users in the management and delivery of care. Increasingly, policy encourages ‘partnerships’ between users and professionals so that users too effectively become team members. In examining this phenomenon, this paper draws on insights from the organisational-sociological literature on team work, which highlights the challenges of bringing together diverse professional groups but which has not to date been applied in contexts where users, too, are included in teams. Using data from a qualitative study of five pilot cancer-genetics projects, in which service users were included in teams responsible for managing and developing new services, it highlights the difficulties involved in making teams of such heterogeneous members—and the paradoxes that arise when this task is achieved. It reveals how the tension between integration and specialisation of team members, highlighted in the literature on teams in general, is especially acute for service users, the distinctiveness of whose contribution is more fragile, and open to blurring.
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The ‘modernisation’ of British public services seeks to broaden public-sector governance networks, bringing the views of third-sector organisations, the public and service users (among others) to the design, management and delivery of... more
The ‘modernisation’ of British public services seeks to broaden public-sector governance networks, bringing the views of third-sector organisations, the public and service users (among others) to the design, management and delivery of welfare. Building on previous analyses of the contradictions generated by these roles, this paper draws on longitudinal qualitative research to enunciate the challenges faced by one third-sector organisation in facilitating service-user influence in an NHS pilot programme, alongside other roles in tension with this advocacy function. The analysis highlights limits in the extent to which lateral governance networks pluralise stakeholder involvement. The ‘framing’ of governance may mean that traditional concerns outweigh the views of new stakeholders such as the third sector and service users. Rather than prioritising wider stakeholders’ views in the design and delivery of public services, placing third-sector organisations at the centre of governance networks may do more to co-opt these organisations in reproducing predominant priorities.
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In attempting to reform public services, governments worldwide have sought to effect change through policies aimed at both transforming structures of public-service provision and facilitating the agency of public servants working within... more
In attempting to reform public services, governments worldwide have sought to effect change through policies aimed at both transforming structures of public-service provision and facilitating the agency of public servants working within these. Various obstacles have been found, however, to impede the effectiveness of such efforts. In this article, the authors examine the role of organizational networks and distributed leadership—two prominent policies aimed at structure and agency, respectively—in the establishment and consolidation of service reform in the English National Health Service. Using a comparative case-study approach, they contrast the trajectories of two attempts to introduce and gain acceptance for service reform, noting important differences of context, process, and outcome between the sites. The findings indicate the importance of dispersed, as well as distributed, leadership in achieving change in a networked public-service setting. Effective leaders may indeed achieve change through the structures and processes of the network. However, the coexistence alongside the network of other organizational forms constrains the ability of leaders to achieve change without complementary action beyond the boundaries of the network.
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Background: There is a growing recognition of the importance of introducing new ways of working into the UK's National Health Service (NHS) and other health systems, in order to ensure that patient care is provided as effectively and... more
Background: There is a growing recognition of the importance of introducing new ways of working into the UK's National Health Service (NHS) and other health systems, in order to ensure that patient care is provided as effectively and efficiently as possible. Researchers have examined the challenges of introducing new ways of working--'organisational innovations'--into complex organisations such as the NHS, and this has given rise to a much better understanding of how this takes place--and why seemingly good ideas do not always result in changes in practice. However, there has been less research on the medium- and longer-term outcomes for organisational innovations and on the question of how new ways of working, introduced by frontline clinicians and managers, are sustained and become established in day-to-day practice. Clearly, this question of sustainability is crucial if the gains in patient care that derive from organisational innovations are to be maintained, rather than lost to what the NHS Institute has called the 'improvement-evaporation effect'.
Methods: The study will involve research in four case-study sites around England, each of which was successful in sustaining its new model of service provision beyond an initial period of pilot funding for new genetics services provided by the Department of Health. Building on findings relating to the introduction and sustainability of these services already gained from an earlier study, the research will use qualitative methods--in-depth interviews, observation of key meetings, and analysis of relevant documents--to understand the longer-term challenges involved in each case and how these were surmounted. The research will provide lessons for those seeking to sustain their own organisational innovations in wide-ranging clinical areas and for those designing the systems and organisations that make up the NHS, to make them more receptive contexts for the sustainment of innovation.
Discussion: Through comparison and contrast across four sites, each involving different organisational innovations, different forms of leadership, and different organisational contexts to contend with, the findings of the study will have wide relevance. The research will produce outputs that are useful for managers and clinicians responsible for organisational innovation, policy makers and senior managers, and academics.
Methods: The study will involve research in four case-study sites around England, each of which was successful in sustaining its new model of service provision beyond an initial period of pilot funding for new genetics services provided by the Department of Health. Building on findings relating to the introduction and sustainability of these services already gained from an earlier study, the research will use qualitative methods--in-depth interviews, observation of key meetings, and analysis of relevant documents--to understand the longer-term challenges involved in each case and how these were surmounted. The research will provide lessons for those seeking to sustain their own organisational innovations in wide-ranging clinical areas and for those designing the systems and organisations that make up the NHS, to make them more receptive contexts for the sustainment of innovation.
Discussion: Through comparison and contrast across four sites, each involving different organisational innovations, different forms of leadership, and different organisational contexts to contend with, the findings of the study will have wide relevance. The research will produce outputs that are useful for managers and clinicians responsible for organisational innovation, policy makers and senior managers, and academics.
Research Interests:
Efforts to ‘modernize’ the clinical workforce of the English National Health Service have sought to reconfigure the responsibilities of professional groups in pursuit of more effective, joined-up service provision. Such efforts have met... more
Efforts to ‘modernize’ the clinical workforce of the English National Health Service have sought to reconfigure the responsibilities of professional groups in pursuit of more effective, joined-up service provision. Such efforts have met resistance from professions eager to protect their jurisdictions, deploying legitimacy claims familiar from the insights of the sociology of professions. Yet to date few studies of professional boundaries have grounded these insights in the specific context of policy challenges to the inter- and intra-professional division of labour, in relation the medical profession and other health-related occupations. In this paper we address this gap by considering the experience of newly instituted general practitioners (family physicians) with a special interest (GPSIs) in genetics, introduced to improve genetics knowledge and practice in primary care. Using qualitative data from four comparative case studies, we discuss how an established intra-professional division of labour within medicine—between clinical geneticists and GPs—was opened, negotiated and reclosed in these sites. We discuss the contrasting attitudes towards the nature of genetics knowledge and its application of GPSIs and geneticists, and how these were used to advance conflicting visions of what the nascent GPSI role should involve. In particular, we show how the claims to knowledge of geneticists and GPSIs interacted with wider policy pressures to produce a rather more conservative redistribution of power and responsibility across the intra-professional boundary than the rhetoric of modernization might suggest.
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Objectives: Developments in genetic knowledge and clinical applications are seen as rendering traditional modes of organizing genetics provision increasingly inappropriate. In common with a number of developed world countries the UK has... more
Objectives: Developments in genetic knowledge and clinical applications are seen as rendering traditional modes of organizing genetics provision increasingly inappropriate. In common with a number of developed world countries the UK has sought to increase the role of primary care in delivering such services. However, efforts to reconfigure service delivery face multiple challenges associated with divergent policy objectives, organizational boundaries and professional cultures. This paper presents findings from an evaluation of an English initiative to integrate genetics into ‘mainstream’ clinical provision in the National Health Service.
Methods: Qualitative research in 11 case-study sites focusing on attempts by pilots funded by the initiative to embed knowledge and provision within primary care illustrating barriers faced and the ways in which these were surmounted.
Results: Lack of intrinsic interest in clinical genetics among primary care staff was compounded by national targets that focused their attention elsewhere and by service structures that rendered genetics a peripheral concern demanding minimal engagement. Established divisions between the commissioning of mainstream and specialist services, along with the pressures of shorter-term targets, impeded ongoing funding.
Conclusions: More wide-ranging policy and organizational support is required if the aim of entrenching genetics knowledge and practice across the Health Service is to be realized.
Methods: Qualitative research in 11 case-study sites focusing on attempts by pilots funded by the initiative to embed knowledge and provision within primary care illustrating barriers faced and the ways in which these were surmounted.
Results: Lack of intrinsic interest in clinical genetics among primary care staff was compounded by national targets that focused their attention elsewhere and by service structures that rendered genetics a peripheral concern demanding minimal engagement. Established divisions between the commissioning of mainstream and specialist services, along with the pressures of shorter-term targets, impeded ongoing funding.
Conclusions: More wide-ranging policy and organizational support is required if the aim of entrenching genetics knowledge and practice across the Health Service is to be realized.
Research Interests:
Recent health policy in England has demanded greater involvement of patients and the public in the commissioning of health and social care services. Public involvement is seen as a means of driving up service quality, reducing health... more
Recent health policy in England has demanded greater involvement of patients and the public in the commissioning of health and social care services. Public involvement is seen as a means of driving up service quality, reducing health inequalities and achieving value in commissioning decisions. This paper presents a summary and analysis of the forms that public involvement in commissioning are to take, along with empirical analysis from a qualitative study of service-user involvement. It is argued that the diversity of constituencies covered by the notion of „public involvement‟, and the breadth of aims that public involvement is expected to achieve, require careful disaggregation. Public involvement in commissioning may encompass a variety of interest groups, whose inputs may include population needs assessment, evaluation of service quality, advocacy of the interests of a particular patient group or service, or a combination of all of these. Each of these roles may be legitimate, but there are significant tensions between them. The extent to which the structures for public involvement proposed recognize these possible tensions is arguably limited. Notably, new Local Involvement Networks (LINks), which will feed into commissioning decisions, are set as the arbiters of these different interests, a demanding role which will require considerable skill, tenacity and robustness if it is to be fulfilled effectively.
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Social-scientific analysis of public-participation initiatives has proliferated in recent years. This review article discusses some key aspects of recent work. Firstly, it analyses some of the justifications put forward for public... more
Social-scientific analysis of public-participation initiatives has proliferated in recent years. This review article discusses some key aspects of recent work. Firstly, it analyses some of the justifications put forward for public participation, drawing attention to differences and overlaps between rationales premised on democratic representation/representativeness and those based on more technocratic ideas about the knowledge that the public can offer. Secondly, it considers certain tensions in policy discourses on participation, focusing in particular on policy relating to the National Health Service and other British public services. Thirdly, it examines the challenges of putting a coherent vision for public participation into practice, noting the impediments that derive from the often-competing ideas about the remit of participation held by different groups of stakeholders. Finally, it analyses the gap between policy and practice, and the consequences of this for the prospects for the enactment of active citizenship through participation initiatives.
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Public participation in health-service management is an increasingly prominent policy internationally. Frequently, though, academic studies have found it marginalized by health professionals who, keen to retain control over... more
Public participation in health-service management is an increasingly prominent policy internationally. Frequently, though, academic studies have found it marginalized by health professionals who, keen to retain control over decision-making, undermine the legitimacy of involved members of the public, in particular by questioning their representativeness. This paper examines this negotiation of representative legitimacy between staff and involved users by drawing on a qualitative study of service-user involvement in pilot cancer-genetics services recently introduced in England, using interviews, participant observation and documentary analysis. In contrast to the findings of much of the literature, health professionals identified some degree of representative legitimacy in the contributions made by users. However, the ways in which staff and users constructed representativeness diverged significantly. Where staff valued the identities of users as biomedical and lay subjects, users themselves described the legitimacy of their contribution in more expansive terms of knowledge and citizenship.
My analysis seeks to show how disputes over representativeness relate not just to a struggle for power according to contrasting group interests, but also to a substantive divergence in understanding of the nature of representativeness in the context of state-orchestrated efforts to increase public participation. This divergence might suggest problems with the enactment of such aspirations in practice; alternatively, however, contestation of representative legitimacy might be understood as reflecting ambiguities in policy-level objectives for participation, which secure implementation by accommodating the divergent constructions of those charged with putting initiatives into practice.
My analysis seeks to show how disputes over representativeness relate not just to a struggle for power according to contrasting group interests, but also to a substantive divergence in understanding of the nature of representativeness in the context of state-orchestrated efforts to increase public participation. This divergence might suggest problems with the enactment of such aspirations in practice; alternatively, however, contestation of representative legitimacy might be understood as reflecting ambiguities in policy-level objectives for participation, which secure implementation by accommodating the divergent constructions of those charged with putting initiatives into practice.
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Public involvement in healthcare is a prominent policy in countries across the economically developed world. A growing body of academic literature has focused on public participation, often presenting dichotomies between good and bad... more
Public involvement in healthcare is a prominent policy in countries across the economically developed world. A growing body of academic literature has focused on public participation, often presenting dichotomies between good and bad practice: between initiatives that offer empowerment and those constrained by consumerism, or between those which rely for recruitment on self-selecting members of the public, and those including a more broad-based, statistically representative group. In this paper I discuss the apparent tensions between differing rationales for participation, relating recent discussions about the nature of representation in public involvement to parallel writings about the contribution of laypeople’s expertise and experience. In the academic literature, there is, I suggest, a thin line between democratic justifications for involvement, suggesting a representative role for involved publics, and technocratic ideas about the potential ‘expert’ contributions of particular subgroups of the public. Analysing recent policy documents on participation in healthcare in England, I seek moreover to show how contemporary policy transcends both categories, demanding complex roles of involved publics which invoke various qualities seen as important in governing the interface between state and society. I relate this to social-theoretical perspectives on the relationship between governmental authority and citizens in late-modern society.
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In seeking to fulfil the ambition of the 2003 genetics white paper, Our Inheritance, Our Future, to ‘mainstream’ genetic knowledge and practices, the Department of Health provided start-up funding for pilot services in various clinical... more
In seeking to fulfil the ambition of the 2003 genetics white paper, Our Inheritance, Our Future, to ‘mainstream’ genetic knowledge and practices, the Department of Health provided start-up funding for pilot services in various clinical areas, including seven cancer genetics projects. To help to understand the challenges encountered by such an attempt at reconfiguring the organization and delivery of services in this field, a programme-level evaluation of the genetics projects was commissioned to consider the organizational issues faced. Using a qualitative approach, this research has involved comparative case-study work in 11 of the pilot sites, including four of the seven cancer genetics pilots. In this paper, the researchers present early findings from their work, focusing in particular on the cancer genetics pilots. They consider some of the factors that have influenced how the pilots have sought to address pre-existing sector, organizational and professional boundaries to these new ways of working. The article examines the relationship between these factors and the extent to which pilots have succeeded in setting up boundary-spanning services, dealing with human-resource issues and creating sustainable, ‘mainstreamed’ provision which attracts ongoing funding in a volatile NHS commissioning environment where funding priorities do not always favour preventive, risk-assessment services.
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This paper reports the results of a postal survey of intermediate care co-ordinators (ICCs) on the organization and delivery of intermediate care services for older people in England, conducted between November 2003 and May 2004.... more
This paper reports the results of a postal survey of intermediate care co-ordinators (ICCs) on the organization and delivery of intermediate care services for older people in England, conducted between November 2003 and May 2004. Questionnaires, which covered a range of issues with a variety of quantitative, ‘tick-box’ and open-ended questions, were returned by 106 respondents, representing just over 35% of primary care trusts (PCTs). We discuss the role of ICCs, the integration of local systems of intermediate care provision, and the form, function and model of delivery of services described by respondents. Using descriptive and statistical analysis of the responses, we highlight in particular the relationship between provision of admission avoidance and supported discharge, the availability of 24-hour care, and the locations in which care is provided, and relate our findings to the emerging evidence base for intermediate care, guidance on implementation from central government, and debate in the literature. Whilst the expansion and integration of intermediate care appear to be continuing apace, much provision seems concentrated in supported discharge services rather than acute admission avoidance, and particularly in residential forms of post-acute intermediate care. Supported discharge services tend to be found in residential settings, while admission avoidance provision tends to be non-residential in nature. Twenty-four hour care in non-residential settings is not available in several responding PCTs. These findings raise questions about the relationship between the implementation of intermediate care and the evidence for and aims of the policy as part of NHS modernization, and the extent to which intermediate care represents a genuinely novel approach to the care and rehabilitation of older people.
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A growing body of literature in geography and other social sciences considers the role of place in the provision of healthcare with particular interests emerging around the role of the psychological, social and cultural aspects of place... more
A growing body of literature in geography and other social sciences considers the role of place in the provision of healthcare with particular interests emerging around the role of the psychological, social and cultural aspects of place in care provision. As healthcare stretches increasingly beyond the traditional four walls of the hospital, so questions of the role of place in practices of care become ever more pertinent. In this paper, we examine the relationship between place and practice in the care and rehabilitation of older people across a range of settings, using qualitative material obtained from interviews and focus groups with nursing, care and rehabilitation staff working in hospitals, clients’ homes and other sites in England. By analysing their testimony on the characteristics of different settings, the aspects of place which facilitate or inhibit rehabilitation and the ways in which place mediates and is mediated by social interaction, we consider how various dimensions of place relate to the power-inscribed relationships between service users, informal carers and professionals as they negotiate the goals of the rehabilitation process. We seek to demonstrate how the physical, psychological and social meanings of place and the social processes engendered by the rehabilitation encounter interact to produce landscapes that are more or less therapeutic, considering in particular the structuring role of state policy and formal healthcare provision in this dynamic.
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The area of Notting Hill in west London has been subject to much media coverage in recent years, which, along with substantial gentrification, has given rise to an image of the area as the epitome of fashionable London. This study... more
The area of Notting Hill in west London has been subject to much media coverage in recent years, which, along with substantial gentrification, has given rise to an image of the area as the epitome of fashionable London. This study investigates the views of those marginal to gentrification and mediated representation on their feelings about the local area, its image and their changing neighbourhoods. Many participants in the research resented some of the more recent changes in Notting Hill and the area's representation in the media. However, in contrast to expectations, most of the more working-class respondents involved in the research did not articulate much emotional attachment to the area. They were more concerned with what might be termed the material aspects of life in Notting Hill: convenience, facilities, safety and so on. In contrast, the more middle-class respondents frequently spoke of their regret of the changes to the area, such as the loss of independent shops, and the reduction in diversity. Paradoxically, the loss of working-class landscapes seems a relatively middle-class worry. The symbolically important landscapes described by working-class respondents were related to more immediate, material issues, in which gentrification was only a relatively minor concern.
Ces dernières années, Notting Hill, quartier de l'ouest de Londres, a souvent été sous les feux des médias qui, parallèlement à un net embourgeoisement, ont fait naître une image symbolisant le Londres à la mode. Cette étude s'intéresse à l'opinion des marginaux de cet embourgeoisement et de cette représentation médiatisée, et à leurs sentiments à l'égard du quartier, de son image et de l'évolution de leur voisinage. Certains des changements les plus récents de Notting Hill et l'image du quartier donnée par les médias ont déplu à de nombreux participants à l'étude. Toutefois, contre toute attente, la plupart des interviewés appartenant à la classe ouvrière n'ont pas formulé d'attachement affectif particulier au quartier. Ils se souciaient davantage de ce qu'on pourrait appeler les aspects matériels de la vie à Notting Hill: confort, services, sécurité, etc. En revanche, les sondés des classes plus moyennes ont souvent évoqué leur regret vis-à-vis des changements locaux, comme la disparition des petits commerces et la réduction de la diversité; paradoxalement, la suppression des paysages ouvriers semble un souci des classes plutôt moyennes. Pour les personnes interrogées dans les classes ouvrières, les paysages importants au plan symbolique étaient associés aux questions matérielles directes, parmi lesquelles l'embourgeoisement n'était qu'une préoccupation relativement mineure.
Ces dernières années, Notting Hill, quartier de l'ouest de Londres, a souvent été sous les feux des médias qui, parallèlement à un net embourgeoisement, ont fait naître une image symbolisant le Londres à la mode. Cette étude s'intéresse à l'opinion des marginaux de cet embourgeoisement et de cette représentation médiatisée, et à leurs sentiments à l'égard du quartier, de son image et de l'évolution de leur voisinage. Certains des changements les plus récents de Notting Hill et l'image du quartier donnée par les médias ont déplu à de nombreux participants à l'étude. Toutefois, contre toute attente, la plupart des interviewés appartenant à la classe ouvrière n'ont pas formulé d'attachement affectif particulier au quartier. Ils se souciaient davantage de ce qu'on pourrait appeler les aspects matériels de la vie à Notting Hill: confort, services, sécurité, etc. En revanche, les sondés des classes plus moyennes ont souvent évoqué leur regret vis-à-vis des changements locaux, comme la disparition des petits commerces et la réduction de la diversité; paradoxalement, la suppression des paysages ouvriers semble un souci des classes plutôt moyennes. Pour les personnes interrogées dans les classes ouvrières, les paysages importants au plan symbolique étaient associés aux questions matérielles directes, parmi lesquelles l'embourgeoisement n'était qu'une préoccupation relativement mineure.
Research Interests:
Efforts to improve the efficiency and responsiveness of public services by harnessing the self-interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social... more
Efforts to improve the efficiency and responsiveness of public services by harnessing the self-interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social services, one way in which British policy-makers have sought to effect such changes has been through the "new community care" of the 1990 NHS and Community Care Act. Key to this is the concept of care management, in which the identification of needs and the provision of services are separated, purportedly with a view to improving advocacy, choice and quality for service users. This paper uses data from a wide-ranging qualitative study of access to social care for older people to examine the success of the policy in these terms, with specific reference to its attempts to harness the rational self-interest of professionals. While care management removes one potential conflict of interests by separating commissioning and provision, the responsibility of social care professionals to comply with organizational priorities conflicts with their role of advocacy for their clients, a tension rendered all the more problematic by the perceived inadequacy of funding. Moreover, the bureaucracy of the care management process itself further negates the approach's supposedly client-centred ethos.
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This paper discusses the evolution of intermediate care (IC) and presents interim observations from a survey of providers in England being conducted as part of a national evaluation. Telephone interviews covering various issues concerning... more
This paper discusses the evolution of intermediate care (IC) and presents interim observations from a survey of providers in England being conducted as part of a national evaluation. Telephone interviews covering various issues concerning the level of provision and style of delivery have been conducted with 70 services to date. Data from these are used to discuss the progress, range and nature of IC in relation to clinician viewpoints and academic and official literature on the subject. IC 'on the ground' is a multiplicitous entity, with provision apparently evolving in accordance with the particularities of local need. While protocols for medical involvement in IC generally appear to be well established, there are some tensions concerning integration of services in a locality, care management processes and questions of flexibility and inclusiveness in relation to eligibility criteria.
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Purpose: Approaches to quality improvement in healthcare based on clinical communities are founded in practitioner networks, peer influence and professional values. However, evidence for the value of this approach, and how to make it... more
Purpose: Approaches to quality improvement in healthcare based on clinical communities are founded in practitioner networks, peer influence and professional values. However, evidence for the value of this approach, and how to make it effective, is spread across multiple disciplines. We review and synthesise relevant literature to provide practical lessons on how to use community-based approaches to improve quality.
Design/methodology/approach: Diverse literatures were identified, analysed and synthesised in a manner which accounted for the heterogeneity of methods, models and contexts they covered.
Findings: A number of overlapping but distinct community-based approaches can be identified in the literature, each suitable for different problems. The evidence for the effectiveness of these is mixed, but there is some agreement on the challenges that those adopting such approaches need to address, and how these can be surmounted.
Practical implications: Key lessons include: the need for coordination and leadership alongside the lateral influence of peers; advantages of starting with a clear programme theory of change; the need for training and resources; dealing with conflict and marginalisation; fostering a sense of community; appropriate use of data in prompting behavioural change; the need for balance between ‘hard’ and ‘soft’ strategies; and the role of context.
Originality/value: The paper brings together diverse literatures with important implications for community-based approaches to quality improvement, drawing on these to offer practical lessons for those engaged in improving healthcare quality in practice.
Design/methodology/approach: Diverse literatures were identified, analysed and synthesised in a manner which accounted for the heterogeneity of methods, models and contexts they covered.
Findings: A number of overlapping but distinct community-based approaches can be identified in the literature, each suitable for different problems. The evidence for the effectiveness of these is mixed, but there is some agreement on the challenges that those adopting such approaches need to address, and how these can be surmounted.
Practical implications: Key lessons include: the need for coordination and leadership alongside the lateral influence of peers; advantages of starting with a clear programme theory of change; the need for training and resources; dealing with conflict and marginalisation; fostering a sense of community; appropriate use of data in prompting behavioural change; the need for balance between ‘hard’ and ‘soft’ strategies; and the role of context.
Originality/value: The paper brings together diverse literatures with important implications for community-based approaches to quality improvement, drawing on these to offer practical lessons for those engaged in improving healthcare quality in practice.
We draw on institutional entrepreneurship theory to analyse the dynamics of institutional change in a healthcare context. The focus of our interest is in the relationship between an institutional entrepreneur’s ‘subject position’, defined... more
We draw on institutional entrepreneurship theory to analyse the dynamics of institutional change in a healthcare context. The focus of our interest is in the relationship between an institutional entrepreneur’s ‘subject position’, defined in terms of their structural and normative legitimacy within the existing institutional landscape, and the nature of the change enacted. We develop this approach through an examination of the implementation of new pathways for cancer genetic services within the English National Health Service. Employing comparative case analysis we show that those who have limited structural legitimacy under prevailing conditions are most willing to engender change, but also least able; whereas those who have strong structural legitimacy are most able, but often least willing. However, those who are able rhetorically to combine a balance of structural and normative legitimacy are most able to produce change. In doing so, we demonstrate the importance of the concept of institutional entrepreneurship to understand healthcare reform.
This paper examines how context shapes team work within the public-service professional bureaucracy. We examine the effects of an interaction between both macro-institutional and local-organizational context upon the micro-negotiation of... more
This paper examines how context shapes team work within the public-service professional bureaucracy. We examine the effects of an interaction between both macro-institutional and local-organizational context upon the micro-negotiation of team work. Specifically, we consider how features of local context mediate professional-institutional effects. Drawing upon neo-institutionalism (Lawrence and Suddaby 2006; Powell and DiMaggio 1991), we view team members as ‘institutional agents’ (Scott 2008), shaping team work in ways that either reproduce or transform professional structures within particular local conditions. Exemplary of international government transformative efforts for public-service enhancement (Newman 2001; Osborne and Gaebler 1992), we focus upon a UK government initiative to reconfigure professional relationships through introducing team work in National Health Service genetic care. Findings from two qualitative, comparative case studies reveal contrasting outcomes: reproduction or transformation of the professional institution, respectively. Specific local conditions — organizational, and human and social in particular — combine to produce these divergent mediating effects towards inertia or change. This highlights the importance of antecedents to team work and taking a historical perspective to understand the influence of context. While the challenges of reconfiguring professional structures through team work are shown, our analysis also suggests optimism regarding possibilities for change, albeit within certain local conditions. The challenge for management and policy-makers becomes the extent to which — and indeed, if at all — such facilitative local environments might be supported.
Background: The purpose of this study was to assess the relationship between skill mix, patient outcomes, length of stay and service costs in older peoples' intermediate care services in England. Methods: We undertook multivariate... more
Background: The purpose of this study was to assess the relationship between skill mix, patient outcomes, length of stay and service costs in older peoples' intermediate care services in England.
Methods: We undertook multivariate analysis of data collected as part of the National Evaluation of Intermediate Care Services. Data were analysed on between 337 and 403 older people admitted to 14 different intermediate care teams. Independent variables were the numbers of different types of staff within a team and the ratio of support staff to professionally qualified staff within teams. Outcome measures include the Barthel index, EQ-5D, length of service provision and costs of care.
Results: Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients.
Conclusions: This study provides limited evidence on the relationship between multidisciplinary skill mix and outcomes in intermediate care services.
Methods: We undertook multivariate analysis of data collected as part of the National Evaluation of Intermediate Care Services. Data were analysed on between 337 and 403 older people admitted to 14 different intermediate care teams. Independent variables were the numbers of different types of staff within a team and the ratio of support staff to professionally qualified staff within teams. Outcome measures include the Barthel index, EQ-5D, length of service provision and costs of care.
Results: Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients.
Conclusions: This study provides limited evidence on the relationship between multidisciplinary skill mix and outcomes in intermediate care services.
Our study provides an analysis of role transition, examining how macro-level influences and micro-level practice interact in framing role transition, with a focus upon professional identity. Empirically, we examine the case of nurses in... more
Our study provides an analysis of role transition, examining how macro-level influences and micro-level practice interact in framing role transition, with a focus upon professional identity. Empirically, we examine the case of nurses in the English NHS, for whom government ‘modernization’ policy has opened up a new occupational position in the delivery of genetics services within a professional bureaucracy. We track the experiences of the nurses through their recruitment to, enactment of, and progress on from, the new genetics role over two years. Our qualitative interview-based study encompasses six comparative cases. Analysis draws upon two linked literatures — role and identity, and sociology of professions — to examine the tension between the identity expected by the profession and the role expected by government policy-makers. While policy encourages reconfiguration of roles and relationships to support the new, less-bounded role, concerns aligned to professional identity mean that inter-professional competition between doctors and nurses, and intra-professional competition within nursing itself, constrain the enactment of the new role. Through our empirical study, we develop literature on role transition through its application to a professionalized context, and sociology of professions literature, within which issues of identity are relatively neglected. Our study demonstrates that the emphasis of identity within a professional bureaucracy lies at the collective level.
Located within a debate about changing organizational forms and new workforce roles this article provides an analysis of policy attempts to modernize the healthcare workforce. Theoretically, the article draws upon sociology of professions... more
Located within a debate about changing organizational forms and new workforce roles this article provides an analysis of policy attempts to modernize the healthcare workforce. Theoretically, the article draws upon sociology of professions literature to focus upon competition within and between professions that impacts upon new roles in the NHS for doctors, designed to combine specialist and generalist knowledge and cross organizational and professional boundaries. The article highlights that attempts by policy-makers to reconfigure the clinical workforce may be constrained due to attempts at occupational closure by more powerful professional groups and by associated concerns about professional identities.
Introduction Joseph Heller’s Catch-22 is regularly invoked to critique the irrationality inherent in supposedly rational bureaucracy. We explore a Catch-22 for policy concerning public involvement in English health care: you have to be... more
Introduction Joseph Heller’s Catch-22 is regularly invoked to critique the irrationality inherent in supposedly rational bureaucracy. We explore a Catch-22 for policy concerning public involvement in English health care: you have to be ordinary to represent the community effectively, but, if you are ordinary, you cannot effectively represent your community.
The nature of public participation groups Starting with community health councils, we trace government policy about involving local people in health care, up to the current arrangements for local involvement networks and show how the above Catch-22 works. We do this in two principal ways. First, by an analysis of some of the unrecognized paradoxes in current government policies designed to populate health-care participation groups and second, by providing a series of narrative vignettes, drawn from our own experiences of working in such groups, which illustrate the nature of the dilemmas members face.
Conclusions Our proposal to get out of the worst of the Catch-22 for effective public involvement groups is (paradoxically) to suggest focusing less on effectiveness, or more precisely, focusing less on those conventional, managerially defined notions of effectiveness that are now pretty much taken for granted within public services. This is because, if bodies like LINks are to do more than provide unthreatening, homogenous and tokenistic public perspectives, they need to be given space and time to pursue their own agendas.
The nature of public participation groups Starting with community health councils, we trace government policy about involving local people in health care, up to the current arrangements for local involvement networks and show how the above Catch-22 works. We do this in two principal ways. First, by an analysis of some of the unrecognized paradoxes in current government policies designed to populate health-care participation groups and second, by providing a series of narrative vignettes, drawn from our own experiences of working in such groups, which illustrate the nature of the dilemmas members face.
Conclusions Our proposal to get out of the worst of the Catch-22 for effective public involvement groups is (paradoxically) to suggest focusing less on effectiveness, or more precisely, focusing less on those conventional, managerially defined notions of effectiveness that are now pretty much taken for granted within public services. This is because, if bodies like LINks are to do more than provide unthreatening, homogenous and tokenistic public perspectives, they need to be given space and time to pursue their own agendas.
In the UK, new intermediate care services have been established to prevent unnecessary hospital admissions, facilitate effective discharge and prevent premature care home admissions. This paper reports findings from a national evaluation... more
In the UK, new intermediate care services have been established to prevent unnecessary hospital admissions, facilitate effective discharge and prevent premature care home admissions. This paper reports findings from a national evaluation of intermediate care, focusing on the relationship between hospital services and intermediate care. Participants included key managers and practitioners involved in the planning, management and delivery of intermediate care in five case study sites. During the study, they identified a range of tensions between hospital services and intermediate care, including concerns about the role and involvement of acute clinicians; the safety, quality and appropriateness of intermediate care; access to and eligibility for intermediate care; a lack of understanding and awareness of intermediate care; and the risk of intermediate care being dominated by acute pressures. Although participants were able to identify several practical ways forward, resolving such fundamental tensions seems to require significant and long-term cultural change in the relationship between acute and intermediate care. Overall, this study raises questions about the extent to which intermediate care will be able to rebalance the current health and social care system and make a substantial contribution to tackling ongoing concerns about emergency hospital admissions and delayed transfers of care.
The authors explore the views of practitioners and managers on the implementation of intermediate care for elderly people across England, including their perceptions of the challenges involved in its implementation, and their assessment... more
The authors explore the views of practitioners and managers on the implementation of intermediate care for elderly people across England, including their perceptions of the challenges involved in its implementation, and their assessment of the main benefits and weaknesses of provision. Qualitative data were collected in five case study sites (English primary care trusts) via semistructured interviews (n = 61) and focus group discussions (n = 21) during 2003 to 2004. Interviewees included senior managers, intermediate care service managers, clinicians and health and social care staff involved in the delivery of intermediate care. The data were analysed thematically using an approach based on the ‘framework’ method. Workforce and funding shortages, poor joint working between health and social care agencies and lack of support/involvement on the part of the medical profession were identified as the main challenges to developing intermediate care. The perceived benefits of intermediate care for service-users included flexibility, patient centredness and the promotion of independence. The ‘home-like’ environment in which services were delivered was contrasted favourably with hospitals. Multidisciplinary teamworking and opportunities for role flexibility were identified as key benefits by staff. Insufficient capacity, problems of access and awareness at the interface between intermediate care and ‘mainstream’ services combined with poor co-ordination between intermediate care services emerged as the main weaknesses in current provision. Despite reported benefits for service-users and staff, the study indicates that intermediate care does not appear to be achieving its full potential for alleviating pressure within health and social care systems. The strengthening of capacity and workforce, improvements to whole systems working and the promotion of intermediate care among doctors and other referrers were identified as key future priorities.
The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of... more
The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of ‘whole systems’ of IC were used, with data collected on a sample of consecutive IC episodes between January 2003 and January 2004. Statistical differences in costs and outcomes associated with different IC services and patient groups were explored. Factors associated with variation in IC episode outcomes (EuroQol EQ-5D and Barthel Index) were explored using an econometric framework. Data were available for 2253 episodes of IC. In terms of Department of Health criteria, a large proportion of patients (up to 47% of those for whom data were available) in this study were inappropriately admitted to IC services. As regards service function, compared to supported discharge, admission avoidance services were associated with both lower costs and greater health and functional gains. These gains appear to be driven, in part, by illness severity (more dependent patients tended to gain most benefit). In addition, these gains appear to be larger where the admission was appropriate. Our work suggests a need for the development and application of robust and reliable clinical criteria for admission to IC, and close co-operation between hospital and community service providers over selection of patients and targeting of IC and acute care services to meet defined clinical need.
Our study responds to a call for research to integrate institutional, organizational and individual levels of analysis in examining the implications for work and employment relations of new organizational forms. We empirically examine the... more
Our study responds to a call for research to integrate institutional, organizational and individual levels of analysis in examining the implications for work and employment relations of new organizational forms. We empirically examine the implementation of network forms of genetics healthcare delivery that cross organizational and professional boundaries. We highlight that less powerful professional groups may find difficulty in enacting boundary-spanning roles associated with new organizational forms. This is due, first, to inconsistency of government policy, which fragments organizations. Second, professional institutions sustain professional hierarchy and power differentials.
You are warmly invited to a symposium on the future of patient and public involvement in health care. This free one-day event will provide a forum for hearing new ideas, sharing knowledge and forging networks with other service users,... more
You are warmly invited to a symposium on the future of patient and public involvement in health care. This free one-day event will provide a forum for hearing new ideas, sharing knowledge and forging networks with other service users, health-care professionals and academics interested in patient and public participation.
