The role of institutional entrepreneurs in reforming healthcare.

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.

Innovation sustainability in challenging health-care contexts: embedding clinically led change in routine practice.

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.

Patients as team members: opportunities, challenges and paradoxes of including patients in multi-professional healthcare teams.

Current healthcare 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.

The medium-term sustainability of organisational innovations in the national health service.

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.

Some unintended effects of teamwork in healthcare.

Teamwork has been emphasised as a key feature of health service reform, essential for safe, efficient and patient-centred care. Bringing together literatures from the sociology of healthcare and organizational theory, we examine how the teamwork phenomenon plays out in practice. Drawing upon material from two ethnographic studies, conducted in an operating theatre and a medical-records department in separate UK NHS hospitals, we explore some of the discursive teamwork practices of healthcare staff. Our analysis presents a very different picture from the normative, evangelistic promotion of teamwork within much management and health policy writing. We reveal how the ambiguity of teamwork opens up opportunities for a complex, diverse range of responses to the managerial discourse among diverse occupational groups, mobilizing the discourse to enact identity in different ways. We highlight how teamwork discourse can be instrumentally co-opted in the reproduction of the very occupational divisions it is designed to ameliorate, or simply ignored as irrelevant when compared to more attractive forms of collective identity. These responses challenge both those who believe that teamwork is a solution to problems in healthcare, as well as those concerned about the oppressive effects of pervasive managerialism.

Bringing genetics into primary care: findings from a national evaluation of pilots in England.

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.

Reconfiguring or reproducing intra-professional boundaries? Specialist expertise, generalist knowledge and the 'modernization' of the medical workforce.

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 to the medical profession and other health-related occupations. In this paper we address this gap by considering the experience of newly instituted general practitioners 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 general practitioners-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.

Spanning boundaries in pursuit of effective knowledge sharing within networks in the NHS.

PURPOSE: The purpose of this paper is to examine power asymmetries in the delivery of genetics healthcare that inhibit knowledge sharing across sector, organisational and professional boundaries. DESIGN/METHODOLOGY/APPROACH: The paper is a longitudinal comparative case study approach, which encompasses semi-structured interviews and observation. FINDINGS: The paper finds politics to be significant in its influence on knowledge sharing across sector, organisational and professional boundaries, but this can be mediated by attending to human and social aspects of the context in which knowledge sharing was expected to take place. RESEARCH LIMITATIONS/IMPLICATIONS: The paper encourages research that evaluates the effect of increased emphasis on human and social aspects of organisational change in pursuit of the "dream" of spanning boundaries and improving knowledge sharing within the NHS. PRACTICAL IMPLICATIONS: The paper shows that structural change appears to be of limited effect in promoting knowledge sharing. Organisational and individual development, career management and performance systems are worthy of attention for the purpose of managing knowledge. ORIGINALITY/VALUE: The paper exposes this assumption as managerialist. Policy-makers assume that professionals are willing and able to share knowledge when delivering healthcare through networks.

National evaluation of NHS genetics service investments: emerging issues from the cancer genetics pilots.

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. These included seven cancer genetics projects, co-funded with Macmillan Cancer Support. 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 National Health Service commissioning environment where funding priorities do not always favour preventive, risk-assessment services.