Governing healthcare: the uses and limits of governmentality in the National Health Service in England.

Using examples from the National Health Service in England, this paper illustrates key features of contemporary healthcare governance: the way decisions are hidden in places that are 'in between' and 'out of reach'; the enrolment of doctors in governing; and the important role played by 'boring things', such as power point slides, flow charts, and forms. The essay shows how anthropological proximity and perspectives can extend and deepen understanding of contemporary political power. It does this firstly by showing the importance of agency in the operation of governmentality, and secondly by illuminating the limits of governmentality. The different elements of governing assemblages, such as global management experts, medical leaders, forms of knowledge and analytical technologies, are brought together through the strategic act of framing. Frames are contested and resisted, requiring more visible forms of control.

"Attending to Collaboration" in Major System Change in Healthcare in England: A Response Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration".

In this short article we comment upon the recent article by Perry et al "Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration. We welcome the engagement with power, history and heuristics in the Perry et al paper. Our article discusses the importance of researcher positionality in Major System Change research, alongside managerial power and the centrality of politics to remaking health and care services. Additionally, we highlight the work of Ansell and Gash focused on 'collaborative governance' and its potential to offer insight in relation to Major System Change.

Using arts-based research in applied health care: An example from an evaluation of NHS dental contract reform in Wales.

OBJECTIVE: Arts-based research (ABR) refers to the use of art in the research process to help generate, interpret and/or communicate knowledge. We used ABR principles to adapt a centre-staging method to complement a more traditional qualitative approach to evaluate participants' views on dental service reform. METHODS: We asked five individuals in the dental health sector in the National Health Service in Wales to select objects to depict their views on the current reform process and their ideal reform process. This process took place alongside traditional semi-structured interviews with the participants. RESULTS: There were three marked differences in the centre-staging process as compared to the interviews: (1) there was a greater use of symbolism by the participants, (2) the participants put a greater focus on the process of change and (3) the participants were more likely to reveal the emotions underlying their assessments of the reform process. CONCLUSIONS: The arts-based approach adopted appeared to be highly accessible and has the potential to be used in a wide range of applications.

Including a wider range of values in healthcare policy: how can public value evaluation help?

To meet future healthcare challenges a broader range of values need to be included in analysis, debate and policy. Different modes of governance foreground and facilitate different values. Collaboration, the governing principle of the newly formed integrated care systems, values the contribution of diverse stakeholders in discussions and decisions, to foster creativity and produce durable solutions to complex problems. Approaches to evaluation reinforce particular values, as captured in the adage 'what's measured is what matters'. New approaches are needed to support the collaborative aims of integrated care systems. Public value evaluation proceeds through values inquiry, establishing what is important to different stakeholders (including policy makers, healthcare staff, patients and communities) as a backdrop to understanding the effects of policies and programmes.

A Board Level Intervention to Develop Organisation-Wide Quality Improvement Strategies: Cost-Consequences Analysis in 15 Healthcare Organisations.

BACKGROUND: Hospital boards have statutory responsibility for upholding the quality of care in their organisations. International research on quality in hospitals resulted in a research-based guide to help senior hospital leaders develop and implement quality improvement (QI) strategies, the QUASER Guide. Previous research has established a link between board practices and quality of care; however, to our knowledge, no board-level intervention has been evaluated in relation to its costs and consequences. The aim of this research was to evaluate these impacts when the QUASER Guide was implemented in an organisational development intervention (iQUASER). METHODS: We conducted a 'before and after' cost-consequences analysis (CCA), as part of a mixed methods evaluation. The analysis combined qualitative data collected from 66 interviews, 60 hours of board meeting observations and documents from 15 healthcare organisations, of which 6 took part on iQUASER, and included direct and opportunity costs associated with the intervention. The consequences focused on the development of an organisation-wide QI strategy, progress on addressing 8 dimensions of QI (the QUASER challenges), how organisations compared to benchmarks, engagement with the intervention and progress in the implementation of a QI project. RESULTS: We found that participating organisations made greater progress in developing an organisation-wide QI strategy and became more similar to the high-performing benchmark than the comparators. However, progress in addressing all 8 QUASER challenges was only observed in one organisation. Stronger engagement with the intervention was associated with the implementation of a QI project. On average, iQUASER costed £23 496 per participating organisation, of which approximately 44% were staff time costs. Organisations that engaged less with the intervention had lower than average costs (£21 267 per organisation), but also failed to implement an organisation-wide QI project. CONCLUSION: We found a positive association between level of engagement with the intervention, development of an organisation-wide QI strategy and the implementation of an organisation-wide QI project. Support from the board, particularly the chair and chief executive, for participation in the intervention, is important for organisations to accrue most benefit. A board-level intervention for QI, such as iQUASER, is relatively inexpensive as a proportion of an organisation's budget.

Sepsis knowledge, skills and attitudes among ward-based nurses.

BACKGROUND: Nurses are in a prime position to identify sepsis early by screening patients for sepsis, a skill that should be embedded into their daily practice. However, compliance with the sepsis bundle remains low. AIMS: To explore the effects of sepsis training on knowledge, skills and attitude among ward-based nurses. METHODS: Registered nurses from 16 acute surgical and medical wards were invited to anonymously complete a questionnaire. FINDINGS: Response rate was 39% (98/250). Nurses with sepsis training had better knowledge of the National Early Warning Score 2 for sepsis screening, and the systemic inflammatory response syndrome (SIRS) criteria, demonstrated a more positive attitude towards sepsis screening and management, were more confident in screening patients for sepsis and more likely to have screened a patient for sepsis. CONCLUSIONS: Sepsis training improves nurses' attitudes, knowledge and confidence with regards to sepsis screening and management, resulting in adherence to evidence-based care, and should become mandatory for all clinical staff.

The role of professional elites in healthcare governance: Exploring the work of the medical director.

Medical leaders occupy a prominent position in healthcare policy in many countries, both in terms of the governance of quality and safety within healthcare organisations, and in broader system-wide governance. There is evidence that having doctors on hospital boards is associated with higher quality services. What is not known is how they have this effect. Analysing data collected from observations, interviews and documents from 15 healthcare providers in England (2014-2019), we elaborate the role of medical directors in healthcare governance as 'translation work', 'diplomatic work', and 'repair work'. Our study highlights the often enduring emotional effects of repeated structural changes to clinical services. It also contributes to theories of professional restratification, showing the work of medical directors as regional 'political elites', and as 'corporate elites' in publicly-funded healthcare systems.

Eastern North Carolina Head Start Teachers' personal and professional experiences with healthy eating and physical activity: a qualitative exploration.

OBJECTIVE: Explore the interrelationship between teachers' personal and professional socio-ecological structures while examining Head Start (HS) teachers' experiences with (1) trying to eat healthy and engage in physical activity (PA) and (2) promote healthy eating and PA in their classrooms. DESIGN: In-depth semi-structured interviews were collected from March through June 2017. Researchers designed the data collection and analysis methods using a phenomenological approach. All interviews were recorded using digital audio and transcribed verbatim. SETTING: Seven HS centres in two rural eastern North Carolina counties. PARTICIPANTS: Teachers (n 15) who had recently participated in a healthy eating and physical activity intervention. Participants were 100 % female, an average age of 43 years (sd 9·6) and primarily Black/African American (93·3 %). RESULTS: Eighteen primary themes were identified providing unique insight into individual, social and environmental determinants that may influence teachers' personal health behaviours and professional health promotion practices. Findings indicated that teachers want to improve health behaviours personally (individual/family health) and professionally (children/families served); however, barriers exist at all levels impacting their ability to improve their own health and facilitate positive behaviours among the children/families they serve. Many teachers observed connections between their personal and professional experiences, but not beyond the individual level. CONCLUSIONS: Study findings highlight the importance of considering and emphasising the potential relationship between personal and professional determinants of health when working with early childhood teachers. Findings from this study may be useful for informing the development, implementation and evaluation of future health promotion interventions using teachers as implementers.

Evaluation of a Policy, Systems, and Environmental-Focused Faith-Based Health Promotion Program.

OBJECTIVE: This study assessed the impact and lessons learned from implementing policy, systems, and environmental (PSE) changes through Faithful Families Thriving Communities (Faithful Families), a faith-based health promotion program, in 3 southern states. METHODS: Faithful Families classes and PSE changes were implemented through a coordinated effort between the Expanded Food and Nutrition Education Program (EFNEP) and Supplemental Nutrition Assistance Program-Education (SNAP-Ed). Changes were measured using a faith community assessment, site reports, and annual reporting. RESULTS: Thirteen faith communities participated in the intervention. A total of 34 PSE changes were implemented across the 3 states, affecting 11 faith communities with 4,810 members across sites. CONCLUSIONS AND IMPLICATIONS: Programs such as Faithful Families can allow EFNEP and SNAP-Ed to coordinate to implement PSE changes in community settings. However, these types of coordinated programs to support faith communities require time for relationship building and trust, adequate training, and strong support for faith-based lay leaders as they carry out this work.

Involving the public in decision-making about large-scale changes to health services: A scoping review.

BACKGROUND: Public involvement in large-scale changes (LSC) to health services is strongly promoted - and even mandated - in several health systems. This scoping review aimed to describe the evidence about how public involvement is conceptualised and conducted in LSC, with what impact, and how different stakeholders perceived this process. METHODS: After searching eight databases, 34 publications were included. Data were extracted and charted using a standardised form. Findings from the literature were discussed with frontline stakeholders. RESULTS: Public involvement remains poorly defined and its aims lack clarity in LSC. Public meetings are most often used to gather public views but raise the issue of representativeness. However, evidence in the literature is scarce about which involvement methods - informative and deliberative - are appropriate for the different stages of the LSC and with what impact. In several cases, the involved public felt they had no influence on decision-making regarding LSC proposals, sometimes leading to an environment of mistrust. In those instances, the public understood the technical arguments for change and actively questioned them, opposed LSC plans and sought alternative routes to voice their views. CONCLUSION: More research and consideration are needed regarding who should be involved, with what purpose and how. We argue that in practice two models of involvement, invited and uninvited participation, coexist and therefore interactions between the two should be given further consideration in LSC.

Exploring the neglected and hidden dimensions of large-scale healthcare change.

Forms of large-scale change, such as the regiona l re-distribution of clinical services, are an enduring reform orthodoxy in health systems of high-income countries. The topic is of relevance and importance to medical sociology because of the way that large-scale change significantly disrupts and transforms therapeutic landscapes, relationships and practices. In this paper we review the literature on large-scale change. We find that the literature is dominated by competing forms of knowledge, such as health services research, and show how sociology can contribute new and critical perspectives and insights on what is for many people a troubling issue.

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service.

BACKGROUND: Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis' typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England. METHODS: We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents. RESULTS: Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of 'slack'-expressed by participants as the 'space to think' and 'someone to do the doing'-and the presence of a functioning board. CONCLUSIONS: Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.

What should be in hospital doctors' continuing professional development?

OBJECTIVE: To ask those most affected by continuing professional development for senior doctors - patients, other professional groups and doctors themselves - what it needs to encompass. DESIGN: The nominal group technique. PARTICIPANTS: Six groups of between seven and nine members (n = 49). Separate groups were held for nurses and therapists (n = 9), patient representatives (n = 8), medical directors (n = 8), consultants (n = 8) and medical trainees (n = 7). An additional group consisted of 'Darzi Fellows' (n = 9), trainee doctors who were undertaking a leadership fellowship. SETTING: Groups were held at the Royal Society of Medicine in London. MAIN OUTCOME MEASURES: Priorities for the content of continuing professional development for senior hospital doctors, ranked in order of importance. Themes derived from analysis of group discussions. RESULTS: We present the ranked priorities of different groups for what should be included in continuing professional development for senior hospital doctors. Analysis of group discussions identified the following three themes: developing and supporting the system of care; changes in the way medicine is practised; and personal wellbeing and caring for colleagues. CONCLUSIONS: The implication of our findings for providers of continuing professional development is to consider the balance of content. Doctors and other healthcare professionals need to keep up with scientific advances and technical developments. But in addition, they need to be adept at working with the system changes required for translation of research into practice, the development of new ways of working, and for the organisational changes that underpin continual quality and safety improvement.

The art and science of non-evaluation evaluation.

This essay considers some limitations of programme theory evaluation in relation to healthcare policies. This approach, which seeks to surface 'programme theories' or construct 'logic models', is often unable to account for empirical observations of policy implementation in real-world contexts. I argue that this failure stems from insufficient theoretical elaboration of the social, cultural and political dimensions of healthcare policies. Drawing from institutional theory, critical theory and discourse theory, I set out an alternative agenda for policy research. I illustrate the issues with respect to programme theory evaluation with examples from my experience of research on large-scale strategic change in the English NHS.

Pastoral power and the promotion of self-care.

In many countries government policy is becoming increasingly reliant on citizens taking greater responsibility for their health and wellbeing and limiting their consumption of public services. In this paper I develop Foucauldian perspectives on the work required to create and maintain responsibilised subjects, focusing on the role of 'pastors' - specialists, experts and therapists who promote desirable subjectivities (Waring and Latif ). Drawing from ethnographic research, I consider how government policies for the promotion of self-care within the English healthcare system not only place increased emphasis on patients taking responsibility for their own health and wellbeing, but also seek to constitute new pastoral subjectivities as responsible for conducting the conduct of patients. I look at efforts to constitute pastoral subjectivities through an assemblage of management knowledge, educational practices and training materials. I argue that efforts to enrol and train pastors are unlikely to accomplish governmental objectives because of the availability of alternative guides for action drawn from professional training, established routines, and forms of social belonging.

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England.

BACKGROUND: Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI). METHODS: We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance. RESULTS: We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders. CONCLUSIONS: This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI.

The experience of potentially vulnerable people during cold weather: implications for policy and practice.

OBJECTIVES: To examine the experience of potentially vulnerable people during cold weather to inform interventions aimed at improving well-being. STUDY DESIGN: Qualitative study. METHODS: Telephone interviews with 35 individuals who could be considered to be potentially vulnerable during cold weather. Individuals were interviewed on two occasions during the winter of 2012-13, one or two days after a level 3 cold weather alert, as defined by the Cold Weather Plan for England, had been issued. RESULTS: Participants were largely unaware of the health risks associated with low temperatures, especially cardiovascular risk. There was a clear distinction between the thermal experience of people in social housing, which was newer, had efficient heating, was well insulated and well-maintained, and owner occupiers living in older, harder to heat homes. Most participants relied on public transport, and many faced arduous journeys to reach basic facilities. Vulnerability to cold was mediated to a significant extent by practical social support from family members. CONCLUSIONS: Resources should be targeted at people in hard to heat homes and those that are socially isolated. The repertoire of initiatives aimed at reducing cold-related mortality and morbidity could usefully be augmented by efforts to reduce social isolation and build community resilience.