Search

Paid carers play an important role in helping older adults with care needs to remain living in their own homes. This paper examines changes in the home care field, specifically the emergence of self‐employed care entrepreneurs ('microentrepreneurs'). To do this, it employs Bourdieu's concepts of field, capital and habitus. Drawing on 105 semi‐structured interviews with stakeholders working in home care, the paper describes how the interaction of changes to field structures, and altered practices of care have challenged the taken‐for‐granted acceptance of traditional, transactional forms of care provision. This process has been highly dependent on local state actors, their ability to mobilise relevant forms of capital and the factors which shaped their habitus. It should be seen within the context of changes to local field structures and the hierarchical classification processes which underpin them. These changes threaten the distribution of capital in the home care field in ways that are beneficial to microentrepreneurs. Bourdieu might categorise these developments as 'partial revolutions', which do not challenge the fundamental axioms of the field. However, for care entrepreneurs, formerly employed as low‐paid home‐care workers, a revolution that is only partial may be better than none at all. [ABSTRACT FROM AUTHOR]

In this paper, we examine how space is integral to the practices and politics of restructuring health and care systems and services and specifically how ideas of assemblage can help understand the remaking of a region. We illustrate our arguments by focusing on health and social care devolution in Greater Manchester, England. Emphasising the open‐ended political construction of the region, we consider the work of assembling different actors, organisations, policies and resources into a new territorial formation that provisionally holds together without becoming a fixed totality. We highlight how the governing of health and care is shaped through the interplay of local, regional and national actors and organisations coexisting, jostling and forging uneasy alliances. Our goal is to show that national agendas continued to be firmly embedded within the regional project, not least the politics of austerity. Yet through keeping the region together as if it was an integrated whole and by drawing upon new global policy networks, regional actors strategically reworked national agendas in attempts to leverage and compete for new resources and powers. We set out a research agenda that foregrounds how the political reorganisation of health and care is negotiated and contested across multiple spatial dimensions simultaneously. [ABSTRACT FROM AUTHOR]

Objectives In many countries increasing use is being made of dental care professionals ( DCPs) to provide aspects of clinical activity previously undertaken by dentists. This study evaluates the differences in practice efficiency associated with the utilisation of DCPs in the provision of General Dental Services in the National Health Service ( NHS) in England. Methods One hundred twenty-one NHS practices completed a questionnaire and shared practice information held at the NHS Business Services Authority. Practice efficiency was estimated using data envelopment analysis with the robustness of the findings checked using Stochastic Frontier Model estimation. Results Dental practices operated at an estimated mean level of technical efficiency of 64%. Variations among practices in the use of DCPs were not associated with variations in practice efficiency after controlling for other staffing levels, patient population characteristics and practice variables. Conclusions The current NHS dental contract limits the potential for efficiency improvements by setting annual practice activity targets that produce little incentive for role substitution. Whilst DCPs may by practising efficiently, this is not reflected in practice-level efficiency, possibly because of dentists using the time released for other non- NHS activity. [ABSTRACT FROM AUTHOR]

This paper discusses changes occurring in the field of English forensic psychiatry which appear to be linked to feelings of discomfort amongst medical professionals who manage care in such settings. These changes are neither the result of a sudden ‘shock’ to the system, nor small improvisations at the margins, but instead appear to reflect a growing perception amongst psychiatrists of accepted field practice as inadequate for some types of patients. To understand how feelings and emotions are implicated in these changes we draw on and develop the work of Pierre Bourdieu to suggest that changes must be seen in the context of field tensions, which have implications for habitus. However, we do not view feelings of discomfort merely as a response to these tensions. Instead we suggest a more dynamic process. The habitus plays a key role in structuring what people pay attention to, how they perceive it and therefore, whether they experience particular feelings in the first place. [ABSTRACT FROM AUTHOR]

Objectives: It is increasingly recognized that the design characteristics of pay-for-performance schemes are importantin determining their impact. One important but under-studied design aspect is the extent to which pay-for-performanceschemes reflect local priorities. The English Department of Health White Paper High Quality Care for All introduced aCommissioning for Quality and Innovation (CQUIN) Framework from April 2009, under which local commissioners andproviders were required to negotiate and implement an annual pay-for-performance scheme. In 2010/2011, theseschemes covered 1.5% (£1.0bn) of NHS expenditure. Local design was intended to offer flexibility to local prioritiesand generate local enthusiasm, while retaining good design properties of focusing on outcomes and processes witha clear link to quality, using established indicators where possible, and covering three key domains of quality (safety;effectiveness; patient experience) and innovation. We assess the extent to which local design achieved these objectives.Methods: Quantitative analysis of 337 locally negotiated CQUIN schemes in 2010/2011, along with qualitative analysisof 373 meetings (comprising 800 hours of observation) and 230 formal interviews (audio-recorded and transcribedverbatim) with NHS staff in 12 case study sites.Results: The local development process was successful in identifying variation in local needs and priorities for qualityimprovement but the involvement of frontline clinical staff was insufficient to generate local enthusiasm around theschemes. The schemes did not in general live up to the requirements set by the Department of Health to ensure thatlocal schemes addressed the original objectives for the CQUIN framework.Conclusions: While there is clearly an important case for local strategic and clinical input into the design of pay-forperformanceschemes, this should be kept separate from the technical design process, which involves defining indicators,agreeing thresholds, and setting prices. These tasks require expertise that is unlikely to exist in each locality. The CQUINframework potentially offered an opportunity to learn how technical design influenced outcome but due to the highdegree of local experimentation and little systematic collection of key variables, it is difficult to derive lessons from thisunstructured experiment about the impact and importance of different technical design factors on the effectiveness ofpay-for-performance. Balancing the policy goal of localism with the objective of improving patient outcomes leads us toconclude that a somewhat firmer national framework would be preferable to a fully locally designed framework. [ABSTRACT FROM AUTHOR]

Objectives To explore the views of NHS dentists in England regarding reforms, which changed their incentive and payment structure. Methods Semi-structured interviews with 35 dentists, digitally recorded, transcribed verbatim and analysed using a constant comparative method. Results Dentists reported changing their behaviour in response to incentives in ways that were likely to have adverse impacts on patients. There was also a loss of trust in NHS paymasters, as well as a loss of faith in the ability to provide high quality care in NHS dentistry. Conclusions Responses suggest that many dentists were quick to change behaviour following the introduction of a revised contractual structure in 2006. The coalition government in the UK has stated its intention to introduce a new NHS dental contract. Our data suggest that part of the process of changing behaviours, norms and attitudes will require the rebuilding of trust in the NHS amongst NHS dentists, as opposed to merely redesigning incentive structures, though the two are related. [ABSTRACT FROM AUTHOR]

Restratification, a process which involves medical elites exerting control over members of their profession, was seen by the US sociologist Eliot Freidson as helping to maintain the continued dominance of the medical model and the profession’s ability to determine its own fate. Drawing on interviews with primary care doctors in England and California this article reports the emergence of new strata or elites, with groups of doctors involved in both surveillance of others and action to improve compliance in deficient individuals and organizations. The article compares responses of primary care doctors to these developments and explores the implications in the context of Freidson’s predictions. [ABSTRACT FROM AUTHOR]

Background: The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems,cognitive processes and social context.Methods/design: A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP]over 2 years) with 100 normal attenders (6.22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation,and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined.Discussion: The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention. [ABSTRACT FROM AUTHOR]

Background Over the past decade there has been a sharp increase in the number of non-profit-sharing salaried doctors employed by practices. This has been accompanied by the introduction of mechanisms to facilitate the entry of other providers into the primary care market. Aim To explore the views of GP principals and salaried doctors on current working practices and the future direction of primary care in England. Design of study Qualitative study using semi-structured interviews. Setting Twenty-two nationally representative practices across England, between February and August 2007. Method Interviews were conducted with 22 principals and seven salaried doctors. A topic guide included questions on motivations for working in primary care, descriptions of working lives, the way in which clinical time was spent, and predictions for future working conditions. Results Significant changes to GP working arrangements were identified, including increasing pursuit of specialist clinical interests by GP principals and increasing employment of salaried GPs. These developments were reported as improving the working lives of principals but also creating a hierarchical structure at practice level that led to resentment among salaried doctors. Many of the salaried GPs felt disenfranchised and disillusioned by the difference in status and autonomy in decision making and the type of work they performed in the practice. Almost all GPs felt uncertain about the future of primary care and were concerned about the potential threat of private providers delivering primary care within the NHS through a largely salaried workforce. Conclusion By failing to recognise the problems of employing an increasingly disenfranchised salaried labour force, GP principals may be undermining the very ethos of general practice they otherwise advocate and recreating smaller versions of the private provider organisations they suggest threaten to corrode NHS primary care. [ABSTRACT FROM AUTHOR]

The article presents a study that explores the unintended consequences of pay-for-performance programs in England and California. The results indicated that English physicians were more likely to report that the program changed the nature of the office visit, while Californian physicians express resentment about pay for performance and are less motivated to act on financial incentives. On the other hand, it is suggested that factors likely to produce unintended consequences should be focused.

Objectives: The creation of a 'safety culture' is a health services priority, yet there is little contemporary research examining the tacit, customary practices that relate to clinical risk. This paper investigates how the ritualistic behaviours of surgeons and anaesthetists serve to normalize risks within the operating theatre, thereby inhibiting organizational learning and enabling such risks to recur. Methods: A two-year ethnographic study in the operating department of a large teaching hospital in the north of England, including observations of the organizational and clinical setting and interviews with 80 members of staff. Results: Three ritualistic types of behaviour are identified and described. Each illustrates the taken-for-granted assumptions associated with clinical risk in the operating theatre and is characterized by a patterned response to risk, the first being to tolerate and endure risk, the second being to accommodate risk through slight modifications to clinical practice and the third being to innovate or implement unorthodox practices to control for risk. Conclusion: These ritualistic behaviours normalize risk within the operating theatre leading to the possibility that some threats will escape appropriate attention and may lead to patient harm. These culturally scripted behaviours also encourage a short-term reactive response to risk that emphasizes the importance of individual coping rather than the more systemic forms of learning associated with participation in incident reporting. This research extends and elaborates upon the current policy orthodoxy to better understand the cultural context of patient safety. [ABSTRACT FROM AUTHOR]

Background: Better management of long-term conditions remains a policy priority, with a focus on improving outcomes and reducing use of expensive hospital services. A number of interventions have been tested, but many have failed to show benefit in rigorous comparative research. In 2016, the NHS Test Beds scheme was launched to implement and test interventions combining digital technologies and pathway redesign in routine health care settings, with each intervention comprising multiple innovations to better realise benefit from their 'combinatorial' effect. We present the evaluation of one of the NHS Test Beds, which combined risk stratification algorithms, practice-based quality improvement and health monitoring and coaching to improve management of long-term conditions in a single health economy in the north-west of England.Methods: The NHS Test Bed was implemented in one clinical commissioning group in the north-west of England (patient population 235,800 served by 36 general practices). Routine administrative data on hospital use (the primary outcome) and a selection of secondary outcomes (data from both hospital and primary care) were collected in the intervention site, and from a comparator area in the same region. We used difference-in-differences analysis to compare outcomes in the NHS Test Bed area and the comparator after initiation of the combinatorial intervention.Results: Tests confirmed the existence of parallel trends in the intervention and comparator sites for hospital outcomes for the period April 2016 to March 2017, and for some of the planned primary care outcomes. Based on 10 months of post-intervention secondary care data and 13 months post-intervention primary care data, we found no significant impact on primary outcomes between the intervention and comparator site, and a significant impact on only one secondary outcome.Conclusion: A combinatorial digital and organisational intervention to improve the management of long-term conditions was implemented across a whole health economy, but we found no evidence of a positive impact on health care utilisation outcomes in hospital and primary care. [ABSTRACT FROM AUTHOR]

The article focuses on the decision of the British government to devolve control of health and social care spending in Greater Manchester. Topics mentioned include establishment of the Greater Manchester Health and Social Care Strategic Partnership Board, devolution movement in England which involves the hand over of powers from the central government to local governments, and intended mechanisms of action, namely subsidiary and local governance, integration, and efficiency and effectiveness.

The article discusses the study on the anxiety of nurses in a teaching hospital in London, England by psychoanalyst Isabel Menzies-Lyth who died earlier on 2009. The development of collective defences in nurses that is institutionalized in working practices and social systems is tackled. Implications for research and policy of health services are examined. Techniques to contain anxiety in nurses are explored.

Background: Pay-for-performance programs are being adopted internationally despite little evidence that they improve patient outcomes. In 2008, a program called Advancing Quality, based on the Hospital Quality Incentive Demonstration in the United States, was introduced in all National Health Service (NHS) hospitals in the northwest region of England (population, 6.8 million). Methods: We analyzed 30-day in-hospital mortality among 134,435 patients admitted for pneumonia, heart failure, or acute myocardial infarction to 24 hospitals covered by the pay-for-performance program. We used difference-in-differences regression analysis to compare mortality 18 months before and 18 months after the introduction of the program with mortality in two comparators: 722,139 patients admitted for the same three conditions to the 132 other hospitals in England and 241,009 patients admitted for six other conditions to both groups of hospitals. Results: Risk-adjusted, absolute mortality for the conditions included in the pay-for-performance program decreased significantly, with an absolute reduction of 1.3 percentage points (95% confidence interval [CI], 0.4 to 2.1; P=0.006) and a relative reduction of 6%, equivalent to 890 fewer deaths (95% CI, 260 to 1500) during the 18-month period. The largest reduction, for pneumonia, was significant (1.9 percentage points; 95% CI, 0.9 to 3.0; P<0.001), with nonsignificant reductions for acute myocardial infarction (0.6 percentage points; 95% CI, −0.4 to 1.7; P=0.23) and heart failure (0.6 percentage points; 95% CI, −0.6 to 1.8; P=0.30). Conclusions: The introduction of pay for performance in all NHS hospitals in one region of England was associated with a clinically significant reduction in mortality. As compared with a similar U.S. program, the U.K. program had larger bonuses and a greater investment by hospitals in quality-improvement activities. Further research is needed on how implementation of pay-for-performance programs influences their effects. (Funded by the NHS National Institute for Health Research.) [ABSTRACT FROM PUBLISHER]