Senior stakeholder views on policies to foster a culture of openness in the English National Health Service: a qualitative interview study.

OBJECTIVES: To examine the experiences of clinical and managerial leaders in the English healthcare system charged with implementing policy goals of openness, particularly in relation to improving employee voice. DESIGN: Semi-structured qualitative interviews. SETTING: National Health Service, regulatory and third-sector organisations in England. PARTICIPANTS: Fifty-one interviewees, including senior leaders in healthcare organisations (38) and policymakers and representatives of other relevant regulatory, legal and third-sector organisations (13). MAIN OUTCOME MEASURES: Not applicable. RESULTS: Participants recognised the limitations of treating the new policies as an exercise in procedural implementation alone and highlighted the need for additional 'cultural engineering' to engender change. However, formidable impediments included legacies of historical examples of detriment arising from speaking up, the anxiety arising from increased monitoring and the introduction of a legislative imperative and challenges in identifying areas characterised by a lack of openness and engaging with them to improve employee voice. Beyond healthcare organisations themselves, recent legal cases and examples of 'blacklisting' of whistle-blowers served to reinforce the view that giving voice to concerns was a risky endeavour. CONCLUSIONS: Implementation of procedural interventions to support openness is challenging but feasible; engineering cultural change is much more daunting, given deep-rooted and pervasive assumptions about what should be said and the consequences of mis-speaking, together with ongoing ambivalences in the organisational environment about the propriety of giving voice to concerns.

Diversity in intermediate care.

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.