Commodification and healthcare in the third sector in England: from gift to commodity-and back?

IMPACT: This article suggests why a different approach may be required for commissioning services from third sector providers than from, say, corporate or public providers. English systems for commissioning third sector providers contain both commodified elements (for example formal procurement, provider competition, commissioner-provider separation) and collaborative, relational elements (for example long-term collaboration, reliance on inter-organizational networks). When the two elements conflicted, commissioners and third sector organizations tended to try to work around the commodified elements in order to preserve and develop the collaborative aspects, which suggests that, in practice, they find de-commodified, collaborative methods better adapted to the commissioning of third sector organizations. ABSTRACT: When publicly-funded services are outsourced, governments still use multiple governance structures to retain some control over the services provided. Using realist methods the authors systematically compared this aspect of community health activities provided by third sector organizations in six English localities during 2020-2022. Two modes of commissioning coexisted. Commodified commissioning largely embodied Washington consensus models of formal, competitive procurement. A contrasting, collaborative mode of commissioning relied more upon relational, long-term co-operation and networking among organizations. When the two modes conflicted, commissioners often favoured the collaborative mode and sought to adjust their commissioning to make it less commodified.

The policy and politics of healthcare corporatisation: The case of the English NHS.

RATIONALE: Few accounts of healthcare corporatisation examine the effects of the 2008 financial crisis. New Politics of the Welfare State (NPWS) theories recognise the relevance of crises but give more attention to programmatic than systemic (structural) retrenchment, and little to healthcare corporatisation. OBJECTIVE: To examine what changes the 2008 financial crisis produced in the pattern of healthcare corporatisation, and the implications for NPWS theories. METHODS: Using administrative data from the English NHS during 1995-2019 we formulated a multi-dimensional index of corporatisation, tested its validity, and used it to analyse longitudinally how the financial crisis affected the balance between the responsibilization of management and re-commodification (introduction of market-like practices) in provider corporatisation. RESULTS: The financial crisis influenced NHS corporatisation through the fiscal austerity with which governments responded. The re-commodification of NHS providers stalled but not the responsibilization of NHS managers. CONCLUSIONS: The corporatisation of NHS providers faltered after the financial crisis. These findings corroborate parts of NPWS theory but also reveal scope for further elaborating its accounts of systemic retrenchment in health systems.

Acquiring and developing healthcare leaders' political skills: an interview study with healthcare leaders.

BACKGROUND: Research suggests health and care leaders need to develop a distinct set of political skills in order to understand and manage the competing interests and agenda that characterise health and care services. AIM: To understand how healthcare leaders describe the acquisition and development of political skills with the aim of providing evidence for leadership development programme. METHODS: A qualitative interview study was carried out between 2018 and 2019 with 66 health and care leaders located within the English National Health Service. Qualitative data were subject to interpretative analysis and coding, with themes related to pre-existing literature on the methods of leadership skill development. RESULTS: The primary method of acquiring and developing political skill is through direct experience in leading and changing services. This is unstructured and incremental in nature with skill development increased through the accumulation of experience. Many participants described mentoring as an important source of political skill development, especially for reflecting on first-hand experiences, understanding the local environment and fine-tuning strategies. A number of participants describe formal learning opportunities as giving them permission to discuss political issues, and providing frameworks for conceptual understanding of organisational politics. Overall, no one approach appears to reflect the changing developmental needs of leaders. CONCLUSIONS: The study suggests that healthcare leaders' development of political skills and behaviours might be supported through an integrative approach that takes into account the evolving learning needs and opportunities at different career stages in the form of a maturation framework.

Navigating the micro-politics of major system change: The implementation of Sustainability Transformation Partnerships in the English health and care system.

OBJECTIVE: To investigate how health and care leaders navigate the micro-politics of major system change (MSC) as manifest in the formulation and implementation of Sustainability and Transformation Partnerships (STPs) in the English National Health Service (NHS). METHODS: A comparative qualitative case study of three STPs carried out between 2018-2021. Data collection comprised 72 semi-structured interviews with STP leaders and stakeholders; 49h of observations of STP executive meetings, management teams and thematic committees, and documentary sources. Interpretative analysis involved developing individual and cross case reports to understand the 'disagreements, 'people and interests' and the 'skills, behaviours and practice'. FINDINGS: Three linked political fault-lines underpinned the micro-politics of formulating and implementing STPs: differences in meaning and value, perceptions of winners and losers, and structural differences in power and influence. In managing these issues, STP leaders engaged in a range of complementary strategies to understand and reconcile meanings, appraise and manage risks and benefits, and to redress longstanding power imbalances, as well as those related to their own ambiguous position. CONCLUSION: Given the lack of formal authority and breadth of system change, navigating the micro-politics of MSC requires political skills in listening and engagement, strategic appraisal of the political landscape and effective negotiation and consensus-building.

Wearing the Future-Wearables to Empower Users to Take Greater Responsibility for Their Health and Care: Scoping Review.

BACKGROUND: Wearables refer to devices that are worn by individuals. In the health care field, wearables may assist with individual monitoring and diagnosis. In fact, the potential for wearable technology to assist with health care has received recognition from health systems around the world, including a place in the strategic Long Term Plan shared by the National Health Service in England. However, wearables are not limited to specialist medical devices used by patients. Leading technology companies, including Apple, have been exploring the capabilities of wearable health technology for health-conscious consumers. Despite advancements in wearable health technology, research is yet to be conducted on wearables and empowerment. OBJECTIVE: This study aimed to identify, summarize, and synthesize knowledge on how wearable health technology can empower individuals to take greater responsibility for their health and care. METHODS: This study was a scoping review with thematic analysis and narrative synthesis. Relevant guidance, such as the Arksey and O'Malley framework, was followed. In addition to searching gray literature, we searched MEDLINE, EMBASE, PsycINFO, HMIC, and Cochrane Library. Studies were included based on the following selection criteria: publication in English, publication in Europe or the United States, focus on wearables, relevance to the research, and the availability of the full text. RESULTS: After identifying 1585 unique records and excluding papers based on the selection criteria, 20 studies were included in the review. On analysis of these 20 studies, 3 main themes emerged: the potential barriers to using wearables, the role of providers and the benefits to providers from promoting the use of wearables, and how wearables can drive behavior change. CONCLUSIONS: Considerable literature findings suggest that wearables can empower individuals by assisting with diagnosis, behavior change, and self-monitoring. However, greater adoption of wearables and engagement with wearable devices depend on various factors, including promotion and support from providers to encourage uptake; increased short-term investment to upskill staff, especially in the area of data analysis; and overcoming the barriers to use, particularly by improving device accuracy. Acting on these suggestions will require investment and constructive input from key stakeholders, namely users, health care professionals, and designers of the technology. As advancements in technology to make wearables viable health care devices have only come about recently, further studies will be important for measuring the effectiveness of wearables in empowering individuals. The investigation of user outcomes through large-scale studies would also be beneficial. Nevertheless, a significant challenge will be in the publication of research to keep pace with rapid developments related to wearable health technology.

Understanding the Political Skills and Behaviours for Leading the Implementation of Health Services Change: A Qualitative Interview Study.

BACKGROUND: The implementation of change in health and care services is often complicated by organisational micro-politics. There are calls for those leading change to develop and utilise political skills and behaviours to understand and mediate such politics, but to date only limited research offers a developed empirical conceptualisation of the political skills and behaviours for leading health services change. METHODS: A qualitative interview study was undertaken with 66 healthcare leaders from the English National Health Service (NHS). Participants were sampled on the basis of their variable involvement in leading change processes, taking into account anticipated differences in career stage, leadership level and role, care sector, and professional backgrounds. Interpretative data analysis led to the development of five themes. RESULTS: Participants' accounts highlighted five overarching sets of political skills and behaviours: personal and inter-personal qualities relating to self-belief, resilience and the ability to adapt to different audiences; strategic thinking relating to the ability to understand the wider and local political landscape from which to develop realistic plans for change; communication skills for engaging and influencing stakeholders, especially for understanding and mediating stakeholders' competing interests; networks and networking in terms of access to resources, and building connections between stakeholders; and relational tactics for dealing with difficult individuals through more direct forms of negotiation and persuasion. CONCLUSION: The study offers further empirical insight the existing literature on healthcare organisational politics by describing and conceptualising the political skills and behaviours of implementing health services change.

'Fast-track' pathway for resectable pancreatic cancer: barriers and facilitators to implementation across a regional network.

INTRODUCTION: The National Institute for Health and Care Excellence guidelines recommend a 'fast-track' approach to avoid preoperative biliary drainage (PBD) when treating resectable pancreatic cancer. For reasons not yet known, there is variable uptake of this approach across the UK. A 'fast-track' pathway which avoids PBD was introduced in University Hospitals Birmingham NHS Foundation Trust (UHB) and referring centres in 2015. METHODOLOGY: Eleven semi-structured interviews were conducted with members of the hepatobiliary multidisciplinary team (MDT) in UHB and referring centres. Barriers and facilitators to pathway implementation were assessed. RESULTS: Facilitators underpinning implementation were collaboration between stakeholders, clinical leadership and careful coordination of referrals. Barriers to implementation included clinician opposition and increased workload. Barriers were mitigated through phased implementation and the appointment of dedicated staff. CONCLUSION: Future work may focus on exploring contextual factors in other tertiary centres and evaluating the emotional impact of 'fast-tracked' versus delayed surgery in patients with resectable pancreatic cancer.

The contribution of political skill to the implementation of health services change: a systematic review and narrative synthesis.

BACKGROUND: The implementation of strategic health system change is often complicated by informal 'politics' in healthcare organisations. Leadership development programmes increasingly call for the development and use of 'political skill' as a means for understanding and managing the politics of healthcare organisations. The primary purpose of this review is to determine how political skill contributes to the implementation of health services change, within and across organisations. The secondary purpose is to demonstrate the conceptual variations within the literature. METHODS: The article is based upon a narrative synthesis that included quantitative, qualitative and mixed methods research papers, review articles and professional commentaries that deployed the concept of political skill (or associated terms) to describe and analyse the implementation of change in healthcare services. RESULTS: Sixty-two papers were included for review drawn from over four decades of empirically and conceptually diverse research. The literature is comprised of four distinct literatures with a lack of conceptual coherence. Within and across these domains, political skill is described as influencing health services change through five dimensions of leadership: personal performance; contextual awareness; inter-personal influence; stakeholder engagement, networks and alliances; and influence on policy processes. CONCLUSION: There is a growing body of evidence showing how political skill can contribute to the implementation of health services change, but the evidence on explanatory processes is weak. Moreover, the conceptualisation of political skill is variable making comparative analysis difficult, with research often favouring individual-level psychological and behavioural properties over more social or group processes.

Explaining health system responses to public reporting of cardiac surgery mortality in England and the USA.

Public reporting of clinical performance is increasingly used in many countries to improve quality and enhance accountability of the health system. The assumption is that greater transparency will stimulate improvements by clinicians in response to peer pressure, patient choice or competition. The international diffusion of public reporting might suggest greater similarity between health systems. Alternatively, national and local contexts (including health system imperatives, professional power and organisational culture) might continue to shape its form and impact, implying continued divergence. The paper considers public reporting in the USA and England through the lens of Scott's 'pillars' institutional framework. The USA was arguably the first country to adopt public reporting systematically in the late 1980s. England is a more recent adopter; it is now being widely adopted through the National Health Service (NHS). Drawing on qualitative data from California and England, this paper compares the behavioural and policy responses to public reporting by health system stakeholders at micro, meso and macro levels and through the intersection of ideas, interests, institutions and individuals through. The interplay between the regulative, normative and cultural-cognitive pillars helps explain the observed patterns of on-going divergence.

Managerial workarounds in three European DRG systems.

PURPOSE: Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy. DESIGN/METHODOLOGY/APPROACH: We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010-12, with additional data collection from key informants and administrative documents continuing in 2018-19 to supplement and update our findings. FINDINGS: Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load 'ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed 'floor' volume. RESEARCH LIMITATIONS/IMPLICATIONS: Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the 'managerial workaround' still further. PRACTICAL IMPLICATIONS: In the case of DRGs, the managerial workarounds were instances of 'constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the 'managerial workaround'. SOCIAL IMPLICATIONS: Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection. ORIGINALITY/VALUE: So far as we are aware, no other study presents and tests the concept of a 'managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

The Chief Registrar role in the UK: leadership capacity and development of hybrid leaders.

PURPOSE: The purpose of the study is to evaluate the first cohort of the Royal College of Physicians' (RCP) Chief Registrar programme in 2016/7. Chief Registrars provide medical leadership capacity through leadership development posts. DESIGN/METHODOLOGY/APPROACH: The study adopted a mixed methods design, comprising a monthly survey of the 21 Chief Registrars in the first cohort, interviews with Chief Registrars, and six cases studies where Chief Registrars and colleagues were interviewed. FINDINGS: Chief Registrars enjoyed high levels of practical, professional, and leadership support from their employing organisations, the RCP, and the Faculty of Medical Leadership and Management. They had high degrees of autonomy in their roles. As a result, roles were enacted in different ways, making direct comparative evaluation problematic. In particular, we identified variation on two dimensions: first, the focus on medical leadership generally, or quality improvement more specifically, and second, the focus on personal development or organisational leadership capacity. RESEARCH LIMITATIONS/IMPLICATIONS: The data are limited and drawn from the first cohort's experience. The Chief Registrar scheme, unlike many other leadership fellowships, maintains a high level of clinical practice (with a minimum 40 per cent leadership work). This suggests a clearer preparation for future hybrid leadership roles. PRACTICAL IMPLICATIONS: This paper may offer some support and guidance for Chief Registrars and those who work with and support them. ORIGINALITY/VALUE: This study adds to the literature on leadership development for doctors in hybrid roles, and highlights the distinctiveness of the scheme compared with other schemes.

Professional autonomy and surveillance: the case of public reporting in cardiac surgery.

Professional autonomy has come under greater scrutiny due to managerialism, consumerism, information and communication technologies (ICT), and the changing composition of professions themselves. This scrutiny is often portrayed as a tension between professional and managerial logics. Recently, medical autonomy has increasingly been shaped in terms of transparency, where publication of clinical performance (via ICT) might be a more pervasive form of surveillance. Such transparency may have the potential for a more explicit managerial logic but is contested by clinicians. This paper applies notions of surveillance to public reporting of cardiac surgery, involving the online publication of mortality rates of named surgeons. It draws on qualitative data from a case-study of cardiac surgeons in one hospital, incorporating interviews with health care managers and national policymakers in England. We examine how managerial logics are mediated by professional autonomy, generating patterns of enrolment, resistance and reactivity to public reporting. The managerial 'gaze' of public reporting is becoming widespread but the surgical specialty is accommodating it, leading to a re-assertion of knowledge, based on professional definitions. The paper assesses whether this form of surveillance is challenging to or being assimilated by the medical profession, thereby recasting the profession itself.

Primary care doctors' understandings of and strategies to tackle health inequalities: a qualitative study.

AIM: To examine general practitioners' knowledge of and their role in tackling health inequalities, in relation to their professional responsibilities. BACKGROUND: Primary care is often seen as being in the frontline of addressing health inequalities and the social determinants of health (SDH). METHODS: A qualitative study with a maximum variety sample of English General Practitioners (GPs). In-depth, semi-structured interviews were held with 13 GPs in various geographical settings; they lasted between 30 and 70 min. Interviews were audio-recorded and transcribed. The analysis involved a constant comparison process undertaken by both authors to reveal key themes. FINDINGS: GPs' understanding of health inequalities reflected numerous perspectives on the SDH and they employ various different strategies in tackling them. This study revealed that GPs' strategies were changing the nature of (medical) professionalism in primary care. We locate these findings in relation to Gruen's model of professional responsibility (comprising a distinction between obligation and aspiration, and between patient advocacy, community participation and political involvement). We conclude that these GPs do not exploit the full potential of their contribution to tackling health inequalities. These findings have implication for policy and practice in other practitioners and in other health systems, as they seek to tackle health inequalities.

Healthcare leadership with political astuteness (HeLPA): a qualitative study of how service leaders understand and mediate the informal 'power and politics' of major health system change.

BACKGROUND: The implementation of strategic health system change is often complicated by the informal politics and power of health systems, such as competing interests and resistant groups. Evidence from other industries shows that strategic leaders need to be aware of and manage such 'organisational politics' when implementing change, which involves developing and using forms of political 'skill', 'savvy' or 'astuteness'. The purpose of this study is to investigate the acquisition, use and contribution of political 'astuteness' in the implementation of strategic health system change. METHODS: The qualitative study comprises four linked work packages. First, we will complete a systematic 'review of reviews' on the topic of political skill and astuteness, and related social science concepts, which will be used to then review the existing health services research literature to identify exemplars of political astuteness in health care systems. Second, we will carry out semi-structured biographical interviews with regional and national service leaders, and recent recipients of leadership training, to understand their acquisition and use of political astuteness. Third, we will carry out in-depth ethnographic research looking at the utilisation and contribution of political astuteness in three contemporary examples of strategic health system change. Finally, we will explore and discuss the study findings through a series of co-production workshops to inform the development and testing of new learning resources and materials for future NHS leaders. DISCUSSION: The research will produce evidence about the relatively under-researched contribution that political skill and astuteness makes in the implementation of strategic health system change. It intends to offer new understanding of these skills and capabilities that takes greater account of the wider social, cultural organisational landscape, and offers tangible lessons and case examples for service leaders. The study will inform future learning materials and processes, and create spaces for future leaders to reflect upon their political astuteness in a constructive and development way. TRIAL REGISTRATION: Researchregistery4020 [23rd April 2018].

The governance of integrated health and social care in England since 2010: great expectations not met once again?

Integrating health and social care has long been a goal of policy-makers and practitioners. Yet, this aim has remained elusive, partly due to conflicting definitions and a weak evidence base. As part of a special edition exploring the use of the TAPIC (transparency, accountability, participation, integrity and capability) framework in different national contexts and inter-agency settings, this article examines the governance of integrated care in England since 2010, focusing on the extent to which thesefive governance attributes are applicable to integrated care in England. The plethora of English policy initiatives on integrated care (such as the 'Better Care Fund', personal health budgets, and 'Sustainability and Transformation Plans') mostly shows signs of continuity over time although the barriers to integrated care often persist. The article concludes that the contribution of integrated care to improved outcomes remains unclear and yet it remains a popular policy goal. Whilst some elements of the TAPIC framework fit less well than others to the case of integrated care, the case of integrated care can be better understood and explained through this lens.