Tackling social inequalities in health: Assessing contexts for implementing integrated health access for people with severe mental illness.

Social inequalities in health are a complex problem that often emerge at the interfaces between different sectors, such as health and social care, and the corresponding transitions between different provider organisations. Vulnerable people are typically in greater need of accessing different sectors of the health system and therefore often experience lack of coherence in their treatment pathway. We aimed to examine the contexts of health systems that influence initiatives concerned with integrated health access. We used the theory of Organizational Fields to study the contexts for implementing Flexible Assertive Community Treatment (FACT) in Central Denmark Region and three municipalities in the region. We collected 33 documents and conducted six qualitative interviews with professionals involved in FACT to understand the contexts of implementing integrated health access. We found that contexts for implementing FACT are highly complex, as they are divided between health and social care (horizontal complexity) and between national and the sub-national levels of the region and the municipalities (vertical complexity). This leads to conflicting demands on implementation. Local contexts of collaboration may offer a lever to handle these demands, but these are likely to vary. Analysis of how complex health system contexts influence implementation is important to understand how changes might become sustainable and help to tackle social inequalities in health.

Comparative health policy goes qualitative: Broadening the focus of research after COVID-19.

The COVID-19 pandemic has pushed health policy frontstage and exposed the stark differences in government capacities to respond to the crisis. This has created new demands for comparative heath policy to support knowledge creation on a large scale. However, comparative health policy has not necessarily been well prepared; studies have focused on health systems and used typologies together with descriptive, quantitative methods. This makes it difficult to capture the multi-level nature of health policy, the diverse actors involved and the many societal facets of governance performance. We argue for broadening the perspective to include health policy as a bottom-up process with diverse interests. This calls for expanding the methodology of comparative health policy by also using approaches that make greater use of explorative, qualitative research. We introduce possible developmental pathways to illustrate what this may look like. The Pan-European Commission shows how to broaden the definition of comparative health policy, notably as transnational and planetary. The gender analysis matrix illustrates how comparative health policy can strengthen its assessment of performance by focussing on gender equity. The street-level bureaucrat framework highlights how analysing frontline work can help conduct small-scale bottom-up comparisons of health policy. Together, these developmental pathways demonstrate the potential to broaden comparative health policy towards greater responsiveness to the societal performance of governments, such as social inequalities created by the COVID-19 pandemic. This also opens opportunities for strengthening the global outlook of comparative health policy.

Who cares?-The unrecognised contribution of homecare nurses to care trajectories.

BACKGROUND: Organisation of patients' trajectories is a critical element of nursing practice. However, nursing practice is mainly expressed in terms of direct patient care, while the practices through which care is organised have received little attention, are poorly acknowledged and lack formal recognition. AIM: To examine the management of care trajectories as provided by homecare nurses. DESIGN: We conducted focus group interviews with 29 Danish homecare nurses. The analysis drew on the evidence based and theoretically informed framework care trajectory management. Care trajectory management is conceptualised as comprising of three organisational components: (1) Trajectory awareness, (2) Trajectory working knowledge and (3) Trajectory articulation. FINDINGS: The organising work of homecare nursing is both complex and unpredictable requiring advanced organisational, collaborative and clinical competences to secure concerted actions in alignment with the needs of the individual patient. Without having any formal obligation homecare nurses took on the responsibility for the coordination of the different activities of the professional actors, and for securing concerted actions. Care trajectory management as provided by homecare nurses reflected a high degree of commitment for patients and illustrated that this type of organising work was driven by the values of the humanistic ethos of nursing. CONCLUSION: The study highlights the strength of the invisible and ongoing organising work of homecare nurses. Care trajectory management in homecare reflects the moral foundation of nursing. Consequently, the professional logic of nursing reflected as direct patient care alone is too narrow. We need to acknowledge the organising work of patients' trajectories as a core task equal to direct patient care. Our study highlights the need for articulating the organising work of homecare nurses and for presenting problematic organisational structures to policymakers and managers. If not, the important organisational work of homecare nurses is at the risk of remaining invisible.

Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries.

BACKGROUND: The health workforce is a key component of any health system and the present crisis offers a unique opportunity to better understand its specific contribution to health system resilience. The literature acknowledges the importance of the health workforce, but there is little systematic knowledge about how the health workforce matters across different countries. AIMS: We aim to analyse the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe (January-May/June 2020), and to assess how health systems prerequisites influence these capacities. MATERIALS AND METHODS: We selected countries according to different types of health systems and pandemic burdens. The analysis is based on short, descriptive country case studies, using written secondary and primary sources and expert information. RESULTS AND DISCUSSION: Our analysis shows that in our countries, the health workforce drew on a wide range of capacities during the first wave of the pandemic. However, health systems prerequisites seemed to have little influence on the health workforce's specific combinations of capacities. CONCLUSION: This calls for a reconceptualisation of the institutional perquisites of health system resilience to fully grasp the health workforce contribution. Here, strengthening governance emerges as key to effective health system responses to the COVID-19 crisis, as it integrates health professions as frontline workers and collective actors.

Health workforce protection and preparedness during the COVID-19 pandemic: a tool for the rapid assessment of EU health systems.

This article is dedicated to the WHO International Year of Health and Care Workers in 2021 in recognition of their commitment during the COVID-19 pandemic. The study aims to strengthen health workforce preparedness, protection and ultimately resilience during a pandemic. We argue for a health system approach and introduce a tool for rapid comparative assessment based on integrated multi-level governance. We draw on secondary sources and expert information, including material from Denmark, Germany, Portugal and Romania. The results reveal similar developments across countries: action has been taken to improve physical protection, digitalization and prioritization of healthcare worker vaccination, whereas social and mental health support programmes were weak or missing. Developments were more diverse in relation to occupational and organizational preparedness: some ad-hoc transformations of work routines and tasks were observed in all countries, yet skill-mix innovation and collaboration were strongest in Demark and weak in Portugal and Romania. Major governance gaps exist in relation to education and health integration, surveillance, social and mental health support programmes, gendered issues of health workforce capacity and integration of migrant healthcare workers (HCW). There is a need to step up efforts and make health systems more accountable to the needs of HCW during global public health emergencies.

Relational coordination in inter-organizational settings. How does lack of proximity affect coordination between hospital-based and community-based healthcare providers?

Coordination among healthcare providers in intra- and inter-organizational networks is critical for the provision of seamless and efficient healthcare. Relational Coordination (RC) represents a type of coordination that enables network participants to manage interdependencies and has consistently been found to improve quality and efficiency of patient care. The majority of RC studies focuses on intra-organizational settings, while less is known about inter-organizational settings. This pilot study examined RC in relation to a collaboration between a hospital-based geriatric team and a community-based acute care team. The study focused especially on how structural challenges due to lack of technological, geographical and organizational proximity between the healthcare providers affected RC, drawing on literature on inter-organizational collaboration. We adopted a qualitative case design to gain an in-depth understanding of barriers and facilitators of interprofessional RC. Data included seven qualitative interviews with healthcare professionals and managers across the two provider teams and 16 hours of participant observations. Findings suggested that core tasks were coordinated through strong RC, while RC in non-core tasks were systematically hindered by structural challenges of the inter-organizational setting. Findings also indicated that RC in core tasks was partly dependent on formal coordination mechanisms to overcome frictions in inter-organizational structures.

Fine for non-attendance in public hospitals in Denmark: A survey of non-attenders' reasons and attitudes.

OBJECTIVE: To investigate non-attending patients' reasons for non-attendance and their general and specific attitudes towards a non-attendance fine. DATA SOURCES: Non-attenders at two hospital departments participating in a trial of fine for non-attendance from May 2015 to January 2017. DESIGN: A quantitative questionnaire study was conducted among non-attenders. DATA COLLECTION: Non-attending patients in the intervention group were invited to complete the questionnaire. The response rate was 39% and the total number of respondents was 71 individuals. PRINCIPAL FINDINGS: The main reason for non-attendance was technical challenges with the digital appointment and with cancelation. The main part of the respondents was generally positive towards a fine for non-attendance. However, approximately the half had a negative attitude towards the actual fine issued. CONCLUSIONS: Technical challenges with appointments and cancelation should get special attention when addressing non-attendance. Danish non-attending patients are primarily positive towards the general principle of issuing a fine for non-attendance. However, a significant proportion of the generally positive, reported a negative specific attitude to the specific fine issued to them. This, however, did not affect their general attitude.

Exploring drivers and challenges in implementation of health promotion in community mental health services: a qualitative multi-site case study using Normalization Process Theory.

BACKGROUND: There is an increased interest in improving the physical health of people with mental illness. Little is known about implementing health promotion interventions in adult mental health organisations where many users also have physical health problems. The literature suggests that contextual factors are important for implementation in community settings. This study focused on the change process and analysed the implementation of a structural health promotion intervention in community mental health organisations in different contexts in Denmark. METHODS: The study was based on a qualitative multiple-case design and included two municipal and two regional provider organisations. Data were various written sources and 13 semi-structured interviews with 22 key managers and frontline staff. The analysis was organised around the four main constructs of Normalization Process Theory: Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. RESULTS: Coherence: Most respondents found the intervention to be meaningful in that the intervention fitted well into existing goals, practices and treatment approaches. Cognitive Participation: Management engagement varied across providers and low engagement impeded implementation. Engaging all staff was a general problem although some of the initial resistance was apparently overcome. Collective Action: Daily enactment depended on staff being attentive and flexible enough to manage the complex needs and varying capacities of users. Reflexive Monitoring: During implementation, staff evaluations of the progress and impact of the intervention were mostly informal and ad hoc and staff used these to make on-going adjustments to activities. Overall, characteristics of context common to all providers (work force and user groups) seemed to be more important for implementation than differences in the external political-administrative context. CONCLUSIONS: In terms of research, future studies should adopt a more bottom-up, grounded description of context and pay closer attention to the interplay between different dimensions of implementation. In terms of practice, future interventions need to better facilitate the translation of the initial sense of general meaning into daily practice by active local management support that occurs throughout the implementation process and that systematically connects the intervention to existing practices.

A call for action to establish a research agenda for building a future health workforce in Europe.

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains insufficiently understood. There is a compelling argument to be made for a comprehensive research agenda to address the questions. With a focus on Europe and taking a health systems approach, we introduce an agenda linked to the 'Health Workforce Research' section of the European Public Health Association. Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. This article highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policy-makers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. This requires dedicated research funding, new academic education programmes, comparative methodology and knowledge transfer and leadership that can help countries to build a people-centred health workforce.

How Intersectoral Health Promotion Changes Professional Practices: A Case Study From Denmark.

Intersectoral health promotion (IHP) has pushed health professions to engage in new tasks and interprofessional ways of working. We studied how care assistants from a nursing home and school teachers implemented a cookery project targeted at children ("Cool Beans") as an example of an IHP project in Denmark. Our aim was to examine the impact of the IHP project on the practices of the professions involved. We used a qualitative case study to investigate joint care and teaching situations with the two professions and their users. Our data consisted of documents, participatory observations, and informal interviews (17 hours) as well as semistructured interviews with professionals (n = 4). We used a sociological institutional framework to analyze the professional practices emerging in joint care and teaching situations and identified three themes of new professional activities: (1) "interplay" related to making different generations collaborate on the tasks involved in the cookery session; (2) "care" concerned with caregiving activities; and (3) "learning" focused on schooling on healthy food and cooking. We conclude that changes in professional practices occurred informally and were induced by the concrete activities in the cookery project. The specific, practical tasks of the IHP project thus offered an important leverage for future interprofessional collaborations.

Professional groups driving change toward patient-centred care: interprofessional working in stroke rehabilitation in Denmark.

BACKGROUND: Patient-centred care based on needs has been gaining momentum in health policy and the workforce. This creates new demand for interprofessional teams and redefining roles and tasks of professionals, yet little is known on how to implement new health policies more effectively. Our aim was to analyse the role and capacity of health professions in driving organisational change in interprofessional working and patient-centred care. METHODS: A case study of the introduction of interprofessional, early discharge teams in stroke rehabilitation in Denmark was conducted with focus on day-to-day coordination of care tasks and the professional groups' interests and strategies. The study included 5 stroke teams and 17 interviews with different health professionals conducted in 2015. RESULTS: Professional groups expressed highly positive professional interest in reorganised stroke rehabilitation concerning patients, professional practice and intersectoral relations; individual professional and collective interprofessional interests strongly coincided. The corresponding strategies were driven by a shared goal of providing needs-based care for patients. Individual professionals worked independently and on behalf of the team. There was also a degree of skills transfer as individual team members screened patients on behalf of other professional groups. CONCLUSIONS: The study identified supportive factors and contexts of patient-centred care. This highlights capacity to improve health workforce governance through professional participation, which should be explored more systematically in a wider range of healthcare services.

Caseload midwifery as organisational change: the interplay between professional and organisational projects in Denmark.

BACKGROUND: The large obstetric units typical of industrialised countries have come under criticism for fragmented and depersonalised care and heavy bureaucracy. Interest in midwife-led continuity models of care is growing, but knowledge about the accompanying processes of organisational change is scarce. This study focuses on midwives' role in introducing and developing caseload midwifery. Sociological studies of midwifery and organisational studies of professional groups were used to capture the strong interests of midwives in caseload midwifery and their key role together with management in negotiating organisational change. METHODS: We studied three hospitals in Denmark as arenas for negotiating the introduction and development of caseload midwifery and the processes, interests and resources involved. A qualitative multi-case design was used and the selection of hospitals aimed at maximising variance. Ten individual and 14 group interviews were conducted in spring 2013. Staff were represented by caseload midwives, ward midwives, obstetricians and health visitors, management by chief midwives and their deputies. Participants were recruited to maximise the diversity of experience. The data analysis adopted a thematic approach, using within- and across-case analysis. RESULTS: The analysis revealed a highly interdependent interplay between organisational and professional projects in the change processes involved in the introduction and development of caseload midwifery. This was reflected in three ways: first, in the key role of negotiations in all phases; second, in midwives' and management's engagement in both types of projects (as evident from their interests and resources); and third in a high capacity for resolving tensions between the two projects. The ward midwives' role as a third party in organisational change further complicated the process. CONCLUSIONS: For managers tasked with the introduction and development of caseload midwifery, our study underscores the importance of understanding the complexity of the underlying change processes and of activating midwives' and managers' interests and resources in addressing the challenges. Further studies of female-dominated professions such as midwifery should offer good opportunities for detailed analysis of the deep-seated interdependence of professional and organisational projects and for identifying the key dimensions of this interdependence.

The making of local hospital discharge arrangements: specifying the role of professional groups.

BACKGROUND: Timely discharge is a key component of contemporary hospital governance and raises questions about how to move to more explicit discharge arrangements. Although associated organisational changes closely intersect with professional interests, there are relatively few studies in the literature on hospital discharge that explicitly examine the role of professional groups. Recent contributions to the literature on organisational studies of the professions help to specify how professional groups in hospitals contribute to the introduction and routinisation of discharge arrangements. This study builds on a view of organisational and professional projects as closely intertwined, where professionals take up organising roles and where organisations shape professionalism. METHODS: The analysis is based on a case study of the introduction and routinisation of explicit discharge arrangements for patients with prostate cancer in two hospitals in Denmark. This represents a typical case that involves changes in professional practice without being first and foremost a professional project. The multiple case design also makes the findings more robust. The analysis draws from 12 focus groups with doctors, nurses and secretaries conducted at two different stages in the process of the making of the local discharge arrangements. RESULTS: From the analysis, two distinct local models of discharge arrangements that connect more or less directly to existing professional practice emerge: an 'add-on' model, which relies on extra resources, special activities and enforced change; and an 'embedded model', which builds on existing ways of working, current resources, and perspectives of professional groups. The two models reveal differences in the roles of professional groups in terms of their stakes and involvement in the process of organisational change: whereas in the 'add on' model the professional groups remain at a distance, in the 'embedded model' they are closely engaged. CONCLUSIONS: In terms of understanding the making of hospital discharge arrangements, the study contributes two sets of insights into the specific roles of professional groups. First, professional interests are an important driver for health professionals to engage in adapting discharge arrangements; and second, professional practice offers a powerful lever for turning new discharge arrangements into organisational routines.

Rethinking organizational culture in intersectoral coordination: the perspective of boundary work.

PURPOSE: The purpose of this paper is to rethink the concept of organizational culture as something that emerges bottom-up by using the sociological concepts of boundary object and boundary work as an analytical lens and to show how this approach can help understand and facilitate intersectoral coordination. DESIGN/METHODOLOGY/APPROACH: We used observations and qualitative interviews to develop "deep" knowledge about processes of intersectoral coordination. The study draws on a conceptual framework of "boundary work" and "boundary objects" to show how a bottom-up perspective on organizational culture can produce better understanding of and pave the way for intersectoral coordination. We use a case of health professionals engaged in two Danish intersectoral programs developing and providing health promotion services for women with gestational diabetes mellitus (GDM). FINDINGS: The study showed how boundary work revolves around negotiations on how to define, understand and act on the diagnosis of GDM. This diagnosis has the characteristics of a "boundary object", being more loosely structured in general terms, but strongly structured in local settings. Boundary objects help connect different professionals and facilitate coordination. The analysis showed how the introduction of time and the concept of "lifelong health promotion" helped to transgress existing organizational and professional boundaries. RESEARCH LIMITATIONS/IMPLICATIONS: The findings contribute to the literature on organizational culture and intersectoral coordination. We highlight the benefits of a practice-oriented, bottom-up perspective for a better understanding of how shared meaning is produced in cross professional coordination and collaboration. While the theoretical implications will be general applicable when studying organizational culture, the implications for practice are sensitive to context and the processes we have described as the outcomes of boundary work are generated from cases that were most likely to provide deep insight into our research topic. PRACTICAL IMPLICATIONS: For practice this can build bridges between organizational and professional boundaries. ORIGINALITY/VALUE: The findings contribute to the literature on organizational culture and intersectoral coordination. We highlight the benefits of a practice-oriented, bottom-up perspective for a better understanding of how shared meaning is produced in cross professional coordination. This may build bridges between organizational and professional boundaries in practice settings.

Task shifting from general practitioners to other health professionals in out-of-hours primary care - a systematic literature review on content and quality of task shifting.

BACKGROUND: Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC). OBJECTIVES: To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC. METHODS: Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary. RESULTS: The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive. CONCLUSION: The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.

Task shifting from general practitioners to other health professionals could increase treatment capacity in out-of-hours primary care.Task shifting occurs for care to patients with less urgent and less complex health issues.The long-term implications of task shifting in out-of-hours primary care should be investigated.

Post-COVID health policy responses to healthcare workforce capacities: A comparative analysis of health system resilience in six European countries.

A cross countries in Europe, health policy is seeking to adapt to the post-pandemic 'permacrisis', where high demands on the healthcare workforce and shortages continue and combine with climate change, and war. The success of these efforts depends on the capacities of the healthcare workforce. This study aims to compare health policy responses to strengthen the capacities of the healthcare workforce and to explore the underpinning dynamics between health systems, policy actors and health policies. The study draws on a qualitative, comparative analysis of Austria, the Czech Republic, Denmark, Germany, Italy and the Netherlands. The findings suggest that policy responses at the national level focused on hospitals and absorptive capacities, while policy responses at local/regional levels also included general practice and adaptive capacities. There were only few examples of policies directed at transformative capacities. The underling dynamics were shaped by health systems, where individual parts are closely connected, by embeddedness in specific service delivery and areas, and by power dynamics. In conclusion, sub-national health policy responses emerge as key to effective responses to the post-pandemic permacrisis, where health professions are central policy actors. Sub-national health policy responses build on existing power relations, but also have the potential to transcend these power relations.

Exploring New Models for Implementing Sustainable Integrated Health Access for People in Vulnerable Positions: Protocol for a Mixed Methods Multiple Case Study.

BACKGROUND: Health care is a strongly universal right across European welfare states; however, social inequalities in health persist. This literature argues that health care organization is an important but overlooked determinant of social inequalities in health, as health systems buffer or amplify structural and individual health determinants. The Client-Centered Coordination Platform (3CP) model offers integrated health access to people with severe mental illness, through core groups of professionals from across health and social services. OBJECTIVE: This study focuses on vulnerable people with severe mental health problems and aims to analyze how the model can give people with severe mental illness more integrated access to health and social care. This can form a stepping-stone for the upscaling of the 3CP model. METHODS: We conduct a 5-year multiple case study of 3 municipalities in Denmark, where 3CP is being implemented. In a 1-year pilot study, we expect to gather quantitative registry data from the municipalities and the Central Denmark Region to explore the characteristics of people included in 3CP. We will also collect qualitative data, including 21 hours of observations; 36 interviews with users, professionals, and managers; and 3 focus groups across the 3 municipalities. In a subsequent, 4-year qualitative study, we aim to conduct 120 hours of observations, 120 interviews, and 24 focus groups. In parallel with the qualitative study, we will facilitate a cocreation process to develop tools for sustaining integrated health access. RESULTS: As of January 2024, we have completed the individual interviews with users of 3CP and professionals and the focus groups. Individual interviews of managers will be conducted during the 1st quarter of 2024. The quantitative data are being collected. CONCLUSIONS: Inequality is one of the greatest challenges that European societies face. Understanding new and innovative approaches to integrated care may provide valuable solutions to the challenges posed. Especially understanding and designing health and social care systems that meet the needs and abilities of those users requiring them most, is vitally important to tackle inequality. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56197.

Improving mental health in chronic care in general practice: study protocol for a cluster-randomised controlled trial of the Healthy Mind intervention.

BACKGROUND: Mental health issues are common among patients with chronic physical conditions, affecting approximately one in five patients. Poor mental health is associated with worse disease outcomes and increased mortality. Problem-solving therapy (PST) may be a suitable treatment for targeting poor mental health in these patients. This study protocol describes a randomised controlled trial of the Healthy Mind intervention, a general practice-based intervention offering PST to patients with type 2 diabetes and/or ischaemic heart disease and poor mental well-being. METHODS: A stepped-wedge cluster-randomised controlled trial with 1-year follow-up will be conducted in Danish general practice. At the annual chronic care consultation, patients with type 2 diabetes and/or chronic ischaemic heart disease will be screened for poor mental well-being. Patients in the control group will be offered usual care while patients in the intervention group will be offered treatment with PST provided by general practitioners (GPs) or general practice staff, such as nurses, who will undergo a 2-day PST course before transitioning from the control to the intervention group. The primary outcome is change in depressive symptoms after 6 and 12 months. Secondary outcomes include change in mental well-being, anxiety, and diabetes distress (patients with type 2 diabetes) after 6 and 12 months as well as change in total cholesterol levels, low-density lipoprotein (LDL) levels, and blood glucose levels (patients with diabetes) after 12 months. Process outcomes include measures of implementation and mechanisms of impact. We aim to include a total of 188 patients, corresponding to approximately 14 average-sized general practices. DISCUSSION: The Healthy Mind trial investigates the impact of PST treatment for patients with chronic disease and poor mental well-being in general practice. This will be the first randomised controlled trial determining the effect of PST treatment for patients with chronic diseases in general practice. The results of this study will provide relevant insights to aid GPs, and general practice staff manage patients with poor mental well-being. TRIAL REGISTRATION: ClinicalTrials.gov NCT05611112. Registered on October 28, 2022.

"A manager in the minds of doctors:" a comparison of new modes of control in European hospitals.

BACKGROUND: Hospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals. METHODS: The research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources. RESULTS: The findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) 'integrated' control with high levels of coordination and coherent patterns for cost and quality controls; (2) 'partly integrated' control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) 'fragmented' control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management. CONCLUSIONS: Our comparison highlights how organisations matter and brings the crucial relevance of 'coordination' of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective.

The contribution of professions to the governance of integrated care: Towards a conceptual framework based on case studies from Denmark.

OBJECTIVE: Good governance of integrated care is key to better health care, but we know little about how professions can help make this happen. Our aim is to introduce a conceptual framework to analyse how professions contribute to the governance of integrated care, and to apply the framework to a secondary analysis of selected case studies from Denmark. METHODS: We developed a framework, which identified the what, how and why of the contribution professions make to the governance of integrated care. We included five qualitative Danish studies, using coordination as an indicator of integrated care. We adopted a thematic approach in our analysis, combining deductive and inductive elements. RESULTS: Health professions engage in highly diverse activities, which fall into closely connected clusters of more formal or more informal coordination. Professions apply many different adaptive mechanisms at different levels to fit coordination into local contexts. Professions are driven by interlocking rationales, where a common focus on patients connects organizational and professional concerns. CONCLUSIONS: Our analytical framework emerges as a useful tool for analysis. The contribution of professions to the governance of integrated care needs greater attention in health policy implementation as it can promote more effective governance of integrated care.