'Holding the line': a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London.

BACKGROUND: Health service reconfigurations are of international interest but remain poorly understood. This article focuses on the use of evidence by senior managerial decision-makers involved in the reconfiguration of stroke services in London 2008-2012. Recent work comparing stroke service reconfiguration in London and Manchester emphasises the ability of senior managerial decision-makers in London to 'hold the line' in the crucial early phases of the stroke reconfiguration programme. In this article, we explore in detail how these decision-makers 'held the line' and ask what the broader power implications of doing so are for the interaction between evidence, health policy and system redesign. METHODS: The research combined semi-structured interviews (n = 20) and documentary analysis of historically relevant policy papers and contemporary stroke reconfiguration documentation published by NHS London and other interested parties (n = 125). We applied a critical interpretive and reflexive approach to the analysis of the data. RESULTS: We identified two forms of power which senior managerial decision-makers drew upon in order to 'hold the line'. Firstly, discursive power, which through an emphasis on evidence, better patient outcomes, professional support and clinical credibility alongside a tightly managed consultation process, helped to set an agenda that was broadly receptive to the overall decision to change stroke services in the capital in a radical way. Secondly, once the essential parameters of the decision to change services had been agreed, senior managerial decision-makers 'held the line' through hierarchical New Public Management style power to minimise the traditional pressures to de-radicalise the reconfiguration through 'top down' decision-making. CONCLUSIONS: We problematise the concept of 'holding the line' and explore the power implications of such managerial approaches in the early phases of health service reconfiguration. We highlight the importance of evidence for senior managerial decision-makers in agenda setting and the limitations of clinical research findings in guiding politically sensitive policy decisions which impact upon regional healthcare systems.

The Role of the Policy Process on Health Service Reconfigurations: Evidence, Path Dependency and Framing Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration".

Historically healthcare services have largely developed on an incremental basis, with various piecemeal changes and some notable policy leaps that illustrate a punctuated equilibrium health policy process. More recently policy-makers have attempted, successfully and unsuccessfully, to reconfigure healthcare services to address perceived problems in the delivery of important services such as stroke, cancer, and trauma. Perry et al provide a welcome addition to research in this area by focusing on the importance of history in a reconfiguration of cancer services in Greater Manchester (GM). Perry et al analyse how and why this configuration was successful after several failed attempts in the past and in this commentary, I want to reflect on the explanatory role health policy analysis can contribute to studying the reconfiguration of healthcare services.

Indigenous health organizations in Australia: connections and capacity.

The health of Aboriginal people is significantly worse than that of the rest of the Australian population. Aboriginal community-controlled health organizations live with uncertainty in terms of funding, and the amount of money spent on indigenous people through mainstream health services is less than that spent on the non-indigenous population, especially when the different needs of these two groups are taken into account. The Aboriginal population is small and widely dispersed, causing problems for policy and funding. This article provides an analysis of the network of health organizations in Victoria, with a specific focus on indigenous health, and analyzes the connections between mainstream and indigenous-specific health services. The research approach involved semi-structured interviews with informants from a range of health organizations within the state. This research illustrates the importance of Aboriginal community-controlled health organizations to the indigenous community. There is evidence that connections between the indigenous and mainstream health systems need to be further developed and strengthened to provide the indigenous population with a high-quality, culturally sensitive, and comprehensive health service.

Partnerships in primary care in Australia: network structure, dynamics and sustainability.

Partnerships represent a prescriptive form of network governance, based on the idea of cooperation. This article has four aims. The first is to describe why network governance and partnerships are important now, and what one particular example - Primary Care Partnerships - is addressing. The second is to analyse the network structure of two of these partnerships, and the third is to examine network dynamics. The fourth aim is to explore relationships and sustainability over the longer term. Two government-funded and steered partnerships, which were established to increase coordination between primary care services in Victoria, Australia, were examined. Annual interviews at three points in time between 2002 and 2005 were used to explore relationships between organizations within these two partnerships. The structure of two different communication networks, based on contacts for work and contacts for strategic information, were examined using social network analysis. Tracing network structures over time highlighted partnership dynamics. The network structures changed over the three years of the study, but an important constant was the continuing centrality of the independent staff employed to manage the partnerships. Over the longer term, it seems to be more important to fund independent partnership staff, rather than people who connect partnerships to the funding agency. If partnerships are seen as valuable in improving service coordination and health outcomes, then long term rather than just start-up funding support is required.

Change capacity: the route to service improvement in primary care.

BACKGROUND: This paper draws on data from five English primary care trust (PCT) case studies which formed part of a larger research project that explored the roles and relationships of clinical managers and their colleagues in periods of change within different healthcare organisations. AIMS: This article uses empirical data to further our understanding of how primary care organisations can successfully implement service improvements. METHOD: Qualitative methods were used to compare across multiple cases. Three methods were utilised comprising semi-structured interviews, document analysis and observation at meetings. Through an iterative process of data coding using the NVivo data analysis software, final conclusions developed and became more explicit. Data were collected between mid-2002 and 2005. RESULTS: Our analysis demonstrates the important influence of context on the change process. The case studies provide evidence of the nature of the relationships between context and progress in organisational change. We identified three interrelated dimensions of organisational context that played a crucial role in the progress or otherwise of service improvement. CONCLUSION: We conclude that primary care organisations need to have three key features in combination to successfully implement service improvements. These are (i) the presence of change leaders, at several levels throughout the organisation; (ii) a coherent change strategy; and (iii) a sound foundation of relationships between managers and clinical professional groups.

The use of patient feedback by hospital boards of directors: a qualitative study of two NHS hospitals in England.

BACKGROUND: Although previous research suggests that different kinds of patient feedback are used in different ways to help improve the quality of hospital care, there have been no studies of the ways in which hospital boards of directors use feedback for this purpose. OBJECTIVES: To examine whether and how boards of directors of hospitals use feedback from patients to formulate strategy and to assure and improve the quality of care. METHODS: We undertook an in-depth qualitative study in two acute hospital National Health Service foundation trusts in England, purposively selected as contrasting examples of the collection of different kinds of patient feedback. We collected and analysed data from interviews with directors and other managers, from observation of board meetings, and from board papers and other documents. RESULTS: The two boards used in-depth qualitative feedback and quantitative feedback from surveys in different ways to help develop strategies, set targets for quality improvement and design specific quality improvement initiatives; but both boards made less subsequent use of any kinds of feedback to monitor their strategies or explicitly to assure the quality of services. DISCUSSION AND CONCLUSIONS: We have identified limitations in the uses of patient feedback by hospital boards that suggest that boards should review their current practice to ensure that they use the different kinds of patient feedback that are available to them more effectively to improve, monitor and assure the quality of care.

The governance of pluralist health care systems: An initial review and typology.

We here argue that study of governance systems within increasingly pluralist health care systems needs to be broadened beyond traditionally public sector orientated literature. We develop an initial typology of multiple governance systems within the English health care sector and derive exploratory questions to inform future empirical investigation. We add to existing literature by considering the coexistence of - and possible tensions between - multiple governance systems in a pluralised health and social care system.

The roles of specialisation and evidence-based practice in inter-professional jurisdictions: A qualitative study of stroke services in England, Sweden and Poland.

This paper investigates how the concepts of clinical specialisation and evidence influence the jurisdictional power of doctors, nurses and therapists involved in stroke care in Sweden, England and Poland. How stroke care has become a distinct specialism across Europe and the role that evidence has played in this development are critically analysed. Five qualitative case studies were undertaken across the three countries, consisting of 119 semi-structured interviews with a range of healthcare workers. The informants were purposively selected and their perspectives of evidence-based practice (EBP) within stroke care were explored. The data were analysed through thematic content analysis. The two key themes that emerged from the data were the health professionals' degrees of EBP and specialisation. The results illustrate how the two concepts of clinical specialisation and evidence are interrelated and work together to influence the different professions' degree of professional jurisdiction. It is concluded that doctors' professional dominance gives them full jurisdiction in stroke care and that nurses' and therapists' degrees of jurisdiction is dependent on their ability to specialise.

Evidence-based practice: reflections from five European case studies.

Background Evidence-based practice (EBP) is now the accepted orthodoxy in clinical practice and developed from evidence-based medicine. EBP is based on a specific type of evidence that is derived from studies based on randomised controlled trials (RCT). This type of evidence is suited to acute medical care and is more problematic for other clinicians such as nurses and therapists, particularly when they are situated within community or primary care settings. Setting Five stroke care services in England (2), Sweden (2) and Poland (1). Aims To reflect on the evidence gained from these case studies to shed light on various aspects of EBP. This paper focuses on three key issues: (1) the importance of context for evidence, (2) the nature of knowledge, and (3) professional hierarchies. Methods Five qualitative case studies into stroke care were carried out in England, Sweden and Poland. One hundred and twenty semi-structured interviews were carried out with a range of healthcare staff who provided specialised and non-specialised stroke care in acute, community and primary care between October 2010 and September 2011. Medical doctors, nurses and different therapists were included in the samples in all five case studies. For this paper, we reflect on some aspects of this work to illuminate the different interprofessional perspectives relating to EBP in stroke care. Results The lack of RCT-based evidence in the community and primary care sectors can lead to the clinicians working in these sectors being perceived as having a lower status. Clinicians use both tacit and encoded knowledge to guide their practice and there existed both intraand interprofessional tensions in these two types of knowledge. The professional hierarchy of stroke teams varies with national context and the role of the non-specialists is less valued in stroke care.

Integration in stroke services: the challenges for primary and community care services.

Objectives A number of evidence-based interventions are now available for stroke patients. Good quality stroke care involves a range of health professionals located across ambulance, hospital, community and primary care services. This study examined the perspectives of healthcare workers involved in stroke care in two different English case study sites on the integration challenges stroke care presents. Methods Two qualitative case studies were carried out, including 45 semi-structured interviews with clinicians and managers associated with two different hospitals providing specialised stroke services. Findings High levels of organisational, functional, service and clinical integration amongst clinicians that deliver emergency and acute stroke care were identified. This is frequently lacking amongst professionals delivering post-acute care. These findings are linked to the prevalence or lack of normative and systemic integration in each respective stage of care. Conclusions Emphasis on the need to treat stroke as an emergency condition in England over recent years has created a context in which normative and systemic integration often occurs amongst clinicians that deliver emergency and acute stroke care, aiding the development of organisational, functional, service and clinical integration across the case study sites. In contrast, integration between hospital and community (rehabilitation and general practice) care is frequently less successful.

The importance of normative integration in stroke services: case study evidence from Sweden and England.

OBJECTIVES: A number of evidence-based interventions are now available for stroke patients. Good-quality stroke care involves a range of health professionals located across ambulance, hospital, community and primary care services. This study examined the perspectives of health-care workers involved in stroke care in Sweden and England on the integration challenges stroke care presents. METHODS: Four qualitative case studies were carried out in Sweden and England, including 95 semistructured interviews with clinicians and managers associated with four different hospitals providing specialized stroke services. FINDINGS: High levels of organizational, functional, service and clinical integration among clinicians that deliver emergency and acute stroke care were identified. This is frequently lacking among professionals delivering postacute care. These findings are linked to the prevalence or lack of normative and systemic integration in each respective stage of care. CONCLUSIONS: Emphasis on the need to treat stroke as an emergency condition in both countries has created a context in which normative and systemic integration often occurs among clinicians that deliver emergency and acute stroke care, aiding the development of organizational, functional, service and clinical integration across the case study sites. In contrast, integration between hospital and community (rehabilitation and general practice) care is frequently less successful.