Search results

We trace the evolution of a new integrated care policy in the English NHS (enhanced health in care homes, EHCH) from pilot model to wider roll out, over a 4-year period, into the circumstances of COVID-19.

Using published evidence and official documentation we compared and contrasted the original EHCH model/framework, subsequent draft specifications and the final proposals, ahead of implementation.

The Primary Care Network EHCH service specification has clearly arisen from the Vanguard programme; however, problems related to GP contracts and COVID-19 means, at least initially, there is likely to be some variability over who will be responsible for delivery. It is unknown whether this service, delivered at pace in the current circumstances, will achieve or affect the outcomes envisaged by the pilots.

This is our interpretation of the developing policy for enhanced health in care homes, which requires further follow-up research. We are beginning our final fieldwork phase in Summer 2020, to report on the Vanguard legacy.

Evaluations of policy success/failure should consider the context and the differing power relations that are present and may impact subsequent take-up and roll-out across the system. We recommend a longitudinal approach to enable a holistic view of policy implementation.

This paper reveals the fragility of health and care policymaking in the current climate. From initial concept, through development and testing, into forced early roll out, our observations reflect the unique impact of a global pandemic shock.

The article aims to argue that the concept of “distributed leadership” lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the “Strategic Action Field Framework” (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar.

Using the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019.

While literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting.

The SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of “social skills” required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.

The purpose of this paper is to investigate the perceptions of key informants on a national support programme for the development of new care models (NCM) in England (2015/2016–2017/2018). It focuses on the perceived facilitators and barriers affecting the development and implementation of the NCM programme and offers some insight into the role of national level support in enabling local integration initiatives.

A set of 29 interviews were carried out with a variety of respondents at the national level (including current and past programme leads, strategic account managers, advisors to the programme and external regulators) between October 2017 and March 2018, and analysed thematically.

A set of facilitative elements of the programme were identified: the development of relationships and alliances, strong local and national leadership, the availability of expert knowledge and skills, and additional funding. Challenges to success included perceived expectations from the national Vanguard programme, oversight and performance monitoring, engagement with regulators, data availability and quality, as well as timetables and timescales. Crucially, the facilitators and challenges were found to interact in dynamic and complex ways, which resulted in significant tensions and ambiguities within the support programme.

While the sample was drawn from a range of different senior players and the authors ensured a diverse sample associated with the NCM support programme, it inevitably cannot be complete and there may have been valuable perspectives absent.

The paper demonstrates that the analysis of facilitators and challenges with respect to the national support of implementation of integrated care initiatives should move beyond the focus on separate influencing factors and address the tensions that the complex interplay among these factors create.

The purpose of this paper is to try and understand how several organisations in one area in England are working together to develop an integrated care programme. Weick’s (1995) concept of sensemaking is used as a lens to examine how the organisations are working collaboratively and maintaining the programme.

Qualitative methods included: non-participant observations of meetings, interviews with key stakeholders and the collection of documents relating to the programme. These provided wider contextual information about the programme. Comprehensive field notes were taken during observations and analysed alongside interview transcriptions using NVIVO software.

This paper illustrates the importance of the construction of a shared identity across all organisations involved in the programme. Furthermore, the wider policy discourse impacted on how the programme developed and influenced how organisations worked together.

The role of leaders from all organisations involved in the programme was of significance to the overall development of the programme and the sustained momentum behind the programme. Leaders were able to generate a “narrative of success” to drive the programme forward. This is of particular relevance to evaluators, highlighting the importance of using multiple methods to allow researchers to probe beneath the surface of programmes to ensure that evidence moves beyond this public narrative.

What is our unit of analysis and by implication what are the boundaries of our cases? This is a question we grapple with at the start of every new project. We observe that case studies are often referred to in an unreflective manner and are often conflated with geographical location. Neat units of analysis and clearly bounded cases usually do not reflect the messiness encountered during qualitative fieldwork. Others have puzzled over these questions. We briefly discuss work to problematise the use of households as units of analysis in the context of apartheid South Africa and then consider work of other anthropologists engaged in multi-site ethnography. We have found the notion of ‘following’ chains, paths and threads across sites to be particularly insightful.

We present two examples from our work studying commissioning in the English National Health Service (NHS) to illustrate our struggles with case studies. The first is a study of Practice-based Commissioning groups and the second is a study of the early workings of Clinical Commissioning Groups. In both instances we show how ideas of what constituted our unit of analysis and the boundaries of our cases became less clear as our research progressed. We also discuss pressures we experienced to add more case studies to our projects. These examples illustrate the primacy for us of understanding interactions between place, local history and rapidly developing policy initiatives. Understanding cases in this way can be challenging in a context where research funders hold different views of what constitutes a case.

The Local Government Act (2000) introduced new Overview and Scrutiny Committees, composed of elected non‐executive councillors, that can respond to proposals from the NHS for changes in services and also set their own agendas for more detailed scrutiny, including of the NHS. Limited capacity has meant that the focus of scrutiny has often been on statutory consultations from the NHS, service provision, NHS organisations and only occasionally on wider issues. However, it is commissioning that is officially seen as the main vehicle for shaping NHS services, so health scrutiny ought logically to address itself more to commissioning than to investigating providers. Practice‐based Commissioning (PBC) was introduced in 2004 with the aim of engaging front‐line clinicians in commissioning health care, though most such commissioning is being undertaken by groups of practices joining together to form consortia, rather than by individual GPs. In principle, this makes it more practicable for health scrutiny to include PBC, but consortia are not statutory bodies and cannot be compelled to participate. We suggest ways in which this omission might be addressed.

With the recent publication of The Engagement Cycle (DH, 2009a), exploring the issues surrounding patient and public involvement (PPI) in World Class Commissioning, it seems timely to look at how this type of involvement/engagement has developed in recent years. Set against official rhetoric that emphasises the importance of PPI in the NHS, this paper is informed by evidence emerging from a three‐year research project into the development of practice‐based commissioning conducted at Manchester University. It is suggested that commissioners (primary care trusts and practice‐based commissioners) need to think deeply about the meaning of public involvement in their context, while at national level strategies should be flexible enough to allow a diversity of approaches which may ultimately allow PPI to flourish.

The purpose of this paper is to explore the practical daily work undertaken by middle‐level managers in Primary Care Trusts (PCTs), focusing upon the micro‐processes by which these managers enact sensemaking in their organisations.

The research took a case study approach, undertaking detailed case studies in four PCTs in England. Data collection included shadowing managers, meeting observations and interviews.

The research elucidated two categories of enactment behaviour exhibited by PCT managers: presence/absence; and the production of artefacts. Being “present” in or “absent” from meetings enacted sensemaking over and above any concrete contribution to the meeting made by the actors involved. This paper explores the factors affecting these processes, and describes the situations in which enactment of sense is most likely to occur. Producing artefacts such as meeting minutes or PowerPoint slides also enacted sense in the study sites in addition to the content of the artefact. The factors affecting this are explored.

The study has practical implications for all managers seeking to maximise their influence in their organisations. It also provides specific evidence relevant to managers working in the new Clinical Commissioning Groups currently being formed in England.

The study expands the understanding of sensemaking in organisations in two important ways. Firstly, it moves beyond discourse to explore the ways in which behaviours can enact sense. Secondly, it explores the distinction between active and unconscious sensemaking.

The purpose of this paper is to explore the early experiences of those involved with the development of Clinical Commissioning Groups (CCGs), examining how the aspiration towards a “clinically-led” system is being realised. The authors investigate emerging leadership approaches within CCGs in light of the criterion for authorisation that calls for “great leaders”.

Qualitative research was carried out in eight case studies (CCGs) across England over a nine-month period (September 2011 to May 2012) when CCGs were in their early development. The authors conducted a mix of interviews (with GPs and managers), observations (at CCG meetings) and examined associated documentation. Data were thematically analysed.

The authors found evidence of two identified approaches to leadership – positive deviancy and responsible guardianship – being undertaken by GPs and managers in the developing CCGs. Historical experiences and past ways of working appeared to be influencing current developments and a commonly emerging theme was a desire for the CCG to “do things differently” to the previous commissioning bodies. The authors discuss how the current reorganisation threatens the guardianship approach to leadership and question if the new systems being implemented to monitor CCGs’ performance may make it difficult for CCGs to retain creativity and innovation, and thus the ability to foster the positive deviant approach to leadership.

This is a large scale piece of qualitative research carried out as CCGs were beginning to develop. It provides insight into how leadership is developing in CCGs highlighting the complexity involved in these roles.

The language used by National Health Service (NHS) “commissioning” managers when discussing their roles and responsibilities can be seen as a manifestation of “identity work”, defined as a process of identifying. This paper aims to offer a novel approach to analysing “identity work” by triangulation of multiple analytical methods, combining analysis of the content of text with analysis of its form.

Fairclough's discourse analytic methodology is used as a framework. Following Fairclough, the authors use analytical methods associated with Halliday's systemic functional linguistics.

While analysis of the content of interviews provides some information about NHS Commissioners' perceptions of their roles and responsibilities, analysis of the form of discourse that they use provides a more detailed and nuanced view. Overall, the authors found that commissioning managers have a higher level of certainty about what commissioning is not rather than what commissioning is; GP managers have a high level of certainty of their identity as a GP rather than as a manager; and both GP managers and non‐GP managers oscillate between multiple identities depending on the different situations they are in.

This paper offers a novel approach to triangulation, based not on the usual comparison of multiple data sources, but rather based on the application of multiple analytical methods to a single source of data. This paper also shows the latent uncertainty about the nature of commissioning enterprise in the English NHS.