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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. 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. [ABSTRACT FROM AUTHOR]

For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients' oral narratives and medical sense-making; and whether a modified form of 'narrative medicine' might mitigate them. We systematically compared 66 general practice patients' own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012-13. Patients' narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients' viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination. [ABSTRACT FROM AUTHOR]

Background: National Health Service (NHS) trusts, which provide the majority of hospital and community health services to the English NHS, are increasingly adopting a 'public firm' model with a board consisting of executive directors who are trust employees and external non-executives chosen for their experience in a range of areas such as finance, health care and management. In this paper we compare the non-executive directors' roles and interests in, and contributions to, NHS trust boards' governance activities with those of executive directors; and examine non-executive directors' approach to their role in board meetings.Methods: Non-participant observations of three successive trust board meetings in eight NHS trusts (primary care trusts, foundation trusts and self-governing (non-foundation) trusts) in England in 2008-9. The observational data were analysed inductively to yield categories of behaviour reflecting the perlocutionary types of intervention which non-executive directors made in trust meetings.Results: The observational data revealed six main perlocutionary types of questioning tactic used by non-executive directors to executive directors: supportive; lesson-seeking; diagnostic; options assessment; strategy seeking; and requesting further work. Non-executive board members' behaviours in holding the executive team to account at board meetings were variable. Non-executive directors were likely to contribute to finance-related discussions which suggests that they did see financial challenge as a key component of their role.Conclusions: The pattern of behaviours was more indicative of an active, strategic approach to governance than of passive monitoring or 'rubber-stamping'. Nevertheless, additional means of maintaining public accountability of NHS trusts may also be required. [ABSTRACT FROM AUTHOR]

Objectives: Health care reforms often include provider diversification, including privatization, to increase competitionand thereby health care quality and efficiency. Donabedian's organizational theory implies that the consequences will varyaccording to the providers' ownership. The aim was to examine how far that theory applies to changes in English NHSprimary medical care (general practice) since 1998, and the consequences for patterns of service provision.Methods: Framework analysis whose categories and structure reflected Donabedian's theory and its implications,populated with data from a systematic review, administrative sources and press rapportage.Results: Two patterns of provider diversification occurred: 'native' diversification among existing providers and pluralprovision as providers with different types of ownership were introduced. Native diversification occurred through:extensive recruitment of salaried GPs; extending the range of services provided by general practices; introducing limitedliability partnerships; establishing GPs with special clinical interests; and introducing a wider range of services for GPs torefer to. All of these had little apparent effect on competition between general practices. Plural provision involved:increased primary care provision by corporations; introducing GP-owned firms; establishing social enterprises (initiallymostly out-of-hours cooperatives); and Primary Care Trusts taking over general practices. Plural provision was on asmaller scale than native diversification and appeared to go into reverse in 2011.Conclusions: Although the available data confirm the implications of Donabedian’s theory, there are exceptions. Nativediversification and plural provision policies differ in their implications for service development. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis. The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety. Methods: A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region.Results: Implementation strategies such as audit, education and training were used. The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p < 0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference −3.5% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97). Conclusions: The documentation of risk assessment improved following the implementation of NICE guidance; it is questionable, however, whether this led to improved patient safety with respect to prescribing appropriate prophylaxis. [ABSTRACT FROM AUTHOR]

Background: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services. Methods: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the "Livewell project". 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative. Results: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory). Conclusions: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies 'negotiated order', managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system. [ABSTRACT FROM AUTHOR]

Background: In quasi-markets governance over healthcare providers is mediated by commissioners. Different commissioners apply different combinations of six methods of control ('media of power') for exercising governance: managerial performance, negotiation, discursive control, incentives, competition and juridical control. This paper compares how English and German healthcare commissioners do so. Methods: Systematic comparison of observational national-level case studies in terms of six media of power, using data from multiple sources. Results: The comparison exposes and contrasts two basic generic modes of commissioning: 1. Surrogate planning (English NHS), in which a negotiated order involving micro-commissioning, provider competition, financial incentives and penalties are the dominant media of commissioner power over providers. 2. Case-mix commissioning (Germany), in which managerial performance, an 'episode based' negotiated order and juridical controls appear the dominant media of commissioner power. Conclusions: Governments do not necessarily maximise commissioners' power over providers by implementing as many media of power as possible because these media interact, some complementing and others inhibiting each other. In particular, patient choice of provider inhibits commissioners' use of provider competition as a means of control. [ABSTRACT FROM AUTHOR]

Background: Previous studies have suggested that greater focus on clinical matters in NHS commissioner and provider Trust Board meetings might improve the range, quality or cost of clinical care. This study reports the extent of clinical focus in Board meetings in three types of NHS Trust and considers the implications for public accountability. Methods: (1) Content analysis of publishedminutes of Boardmeetings from 105 randomly selected NHS Trusts in 2008/09. (2) Structured observation of 24 Board meetings in a qualitative sub-sample of eight of the above Trusts in 2008/09. Results: The percentage of clinical items among the items discussed by NHS Trust Boards ranged from 0% to 51%, but did not differ by Trust type. Primary Care Trusts (PCTs) recorded more items than NHS Trusts and NHS Foundation Trusts because of PCTs' dual role as service providers and commissioners. There were significant differences between Trusts' board meetings in the numbers of clinical items concerning service design, clinical outcomes and activity levels. The availability and accessibility of supposedly publicly-available minutes from NHS Foundation Trust Board meetings was sometimes problematic. Observation of meetings revealed a number of dynamics not evident in the minutes. Board meetings were generally chair-led (conducted according to the chair's discretion); collegial; had similar levels and extent of discussion from the non-executive directors, with a focus on current policy initiatives. Boards differed in the extent of public questioning, how they exercised internal governance over the provision and quality of patient care, and the extent of pre-planning before the Board meeting. Published minutes were not always an accurate record of meetings. Conclusions: Findings illuminate important transparency issues which should be given careful consideration in the English NHS. [ABSTRACT FROM AUTHOR]

Abstract: Many health systems now use networks as governance structures. Network ‘macroculture’ is the complex of artefacts, espoused values and unarticulated assumptions through which network members coordinate network activities. Knowledge of how network macroculture during 2006–2008 develops is therefore of value for understanding how health networks operate, how health system reforms affect them, and how networks function (and can be used) as governance structures. To examine how quasi-market reforms impact upon health networks'' macrocultures we systematically compared longitudinal case studies of these impacts across two care networks, a programme network and a user-experience network in the English NHS. We conducted interviews with key informants, focus groups, non-participant observations of meetings and analyses of key documents. We found that in these networks, artefacts adapted to health system reform faster than espoused values did, and the latter adapted faster than basic underlying assumptions. These findings contribute to knowledge by providing empirical support for theories which hold that changes in networks'' core practical activity are what stimulate changes in other aspects of network macroculture. The most powerful way of using network macroculture to manage the formation and operation of health networks therefore appears to be by focusing managerial activity on the ways in which networks produce their core artefacts. [Copyright &y& Elsevier]

Infancy is a crucial time for interventions to reduce later developmental difficulties. In England, recent policy has required children's service delivery to be redesigned to attend to infant mental health across all four tiers of NHS provision through interagency networks of child-care professionals. The policy identifies child-care social workers as primary care professionals, able to recognize early infant mental health problems, promote mental health and prevent deterioration. Our paper explores whether, as a profession, English child-care social workers are well prepared in terms of their knowledge, ideological beliefs and professional acculturation to implement such changes to their practice. Empirical information is provided from a funded, independent evaluation of the implementation of the NSF policy at a local level. Data from professional focus group interviews describe and compare the differing professional ideologies and professional practice preferences within the infant mental health network of an English NHS Primary Care Trust in an urban local authority. The findings identified obstacles that were personal-ideological, cultural and structural in nature. Progress towards achieving the NSF policy standards appeared slight. [ABSTRACT FROM AUTHOR]

Objective: To assess the impacts of different forms of case management for people aged over 65 years at risk of unplanned hospital admission, in particular the impacts upon patients, carers and health service organization in English primary care; and, in these respects, compare the Evercare model with alternatives. Methods: Multiple qualitative case studies comparing case management in nine English Primary Care Trusts which piloted the Evercare model of case management and four sites which implemented alternative forms of case management between 2003 and 2005. Data were obtained from 231 interviews with patients, carers and other key informants, and from content analysis of documents and observation of meetings. Results: All the projects established functioning case management services, but none led to major service reorganization or savings elsewhere in the health care system. Many informants reported examples of admissions which case management had prevented, but overall hospital admissions did not significantly change, possibly due to increased case-finding. Patients and carers valued case management for improving access to health care, increasing psychosocial support and improving communication with health professionals. Conclusion: Case management was highly valued by patients and their carers, but there were few major differences in outcomes between Evercare and other models. [ABSTRACT FROM AUTHOR]

Background: Little research attention has been given to attempts to implement organisational initiatives to improve quality of care for mental health care, where there is a high level of indeterminacy and clinical judgements are often contestable. This paper explores recent efforts made at an organisational level in England to improve the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'. Methods: Framework analysis, based on the Normalisation Process Model (NPM), of attempts over a five year period to develop clinical governance for primary mental health services in Primary Care Trusts (PCTs). The data come from a longitudinal qualitative multiple case-study approach in a purposive sample of 12 PCTs, chosen to reflect a maximum variety of organisational contexts for mental health care provision. Results: The constant change within the English NHS provided a difficult context in which to attempt to implement 'clinical governance' or, indeed, to reconstruct primary mental health care. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, and a lack of actors with the power or skills to set about realising it, the actors in 'clinical governance' had little shared knowledge or understanding of their role in improving the quality of mental health care. There was a lack of ownership of 'mental health' as an integral, normalised part of primary care. Conclusion: Despite some achievements in regard to monitoring and standardisation of prescribing practice, mental health care in primary care seems to have so far largely eluded the gaze of 'clinical governance'. Clinical governance in English primary mental health care has not yet become normalised. We make some policy recommendations which we consider would assist in the process normalisation and suggest other contexts to which our findings might apply. [ABSTRACT FROM AUTHOR]

Abstract: Hirschman contrasts exit and voice as ‘recuperation’ mechanisms for making organisations responsive to users. However, the emergence of health-care quasi-markets and of network governance structures since Hirschman necessitate revising his theory, for they complicate the relationships between governance structures and recuperation mechanisms. Using a case study of nine primary care trusts (PCTs), this paper analyses the recuperation mechanisms, governance structures and relations between them in primary care in England. User voice can be exercised through dedicated networks besides hierarchies. As well as the ‘user exit’ described by Hirschman, two new ‘exit’ mechanisms now exist in quasi-markets. Commissioner exit occurs when a third-party payer stops using a given provider. Professional proxy exit occurs when a general practitioner (GP) fund-holder (or analogous budget-holder) behaves similarly. Neither exit mechanism requires the existence of mechanisms for user exit from healthcare purchasers, provided strong voice mechanisms exist instead to make commissioners responsive to users’ demands. Establishing such voice mechanisms is not straightforward, however, as the experience of English PCTs illustrates. [Copyright &y& Elsevier]

Providing more information for the public about the range and quality of health services is an important part of improving accountability, quality and public responsiveness. Most sources of information to date have failed to address the information needs of people about their local services. The launch in England in 2002 of a new publication,Guides to Local Health Services, was designed to address this deficiency. We conducted an audit of the firstGuides, and surveyed those responsible for their production, in order to examine theGuides’ development, content, presentation and dissemination, and to critique the purpose of the initiative.A semi-structured questionnaire survey of those responsible for producing theGuides, and an audit of theGuidesproduced by Primary Care Trusts (PCTs).Most PCTs complied with central guidance about structure and content, but in meeting multiple requirements theGuideslost their clarity of purpose. The content was dominated by information relating to financial and strategic accountability. In producing theGuides, external consultation was limited, particularly with the public but also with local partnership providers of health and social care. The main issues were the lack of a clear focus forGuideinformation, the level of central direction, the short production lead times, difficulties with distribution, and the many competing demands being made on PCT resources.Guidecontent should be clearly focused on information that the public wants. Greater responsibility should be devolved to front line PCT staff to determine content in consultation with local users. [ABSTRACT FROM AUTHOR]

In England, the quality of clinical work is being regulated in new ways following recent developments in “clinical governance” policy and apparent failures in the previous system of medical self-regulation. Using multiple case studies, this paper examines how these changes are affecting professional governmentality and discipline in general practice. Formal organizational structures play little role in clinical governance there. Clinical quality is managed largely through semi-formal networks, relying on medical self-surveillance. Compliance is achieved largely by discursive appeals to the legitimacy of clinical governance, but local GPs’ leaders also argue that governments might otherwise regulate medical practice more actively. As yet the effects of clinical governance activity on service delivery are slight. Professional self-regulation is replacing permissive exception management with more collegial, directive methods. [ABSTRACT FROM AUTHOR]

English National Health Service general practice is being restructured through the introduction of primary care groups (PCGs) and trusts (PCTs), and the personal medical services (PMS) schemes. Theories of GPs’ professional organization have to be modernized accordingly. Past theories have tended to concentrate on the occupational level rather than consider the effects of different forms of market and quasi–market on practitioners’ income and their ability to control their everyday practice. This paper extends the theory of professionalization, as an occupational group’s strategy for control over its work, to cover these matters, and thereby hypothesizes an explanation of GP responses to current changes in NHS primary health care. Case study data from four PCGs and four PMS pilots suggest that general practitioners are responding in some cases by defending enclaves of traditional general practice; in others by concentrating on clinical rather than managerial interests; and in others again by forming a new dominant coalition with NHS managers. Restratification seems to be beginning in NHS general practice although other policy developments may yet prevent it. Researchers should monitor this potentially important change as PCTs form. [ABSTRACT FROM AUTHOR]

Objectives To investigate the involvement of users in clinical governance activities within Primary Care Groups (PCGs) and Trusts (PCTs). Drawing on policy and guidance published since 1997, the paper sets out a framework for how users are involved in this agenda, evaluates practice against this standard and suggests why current practice for user involvement in clinical governance is flawed and why this reflects a flaw in the policy design as much as its implementation. Design Qualitative data comprising semi-structured interviews, reviews of documentary evidence and relevant literature. Setting Twelve PCGs/PCTs in England purposively selected to provide variation in size, rurality and group or trust status. Participants Key stakeholders including Lay Board members (n =12), Chief Executives (CEs) (n = 12), Clinical Governance Leads (CG leads) (n = 14), Mental Health Leads (MH leads) (n = 9), Board Chairs (n =2) and one Executive Committee Lead. Results Despite an acknowledgement of an organizational commitment to lay involvement, in practice very little has occurred. The role of lay Board members in setting priorities and implementing and monitoring clinical governance remains low. Beyond Board level, involvement of users, patients of GP practices and the general public is patchy and superficial. The PCGs/PCTs continue to rely heavily on Community Health Councils (CHCs) as a conduit or substitute for user involvement; although their abolition is planned, their role to be fulfilled by new organizations called Voices, which will have an expanded remit in addition to replacing CHCs. Conclusions Clarity is required about the role of lay members in the committees and subcommittees of PCGs and PCTs. Involvement of the wider public should spring naturally from the questions under consideration, rather than be regarded as an end in itself. [ABSTRACT FROM AUTHOR]

Background: Offenders frequently have substantial healthcare needs and, like many other socially marginalised groups, often receive healthcare in inverse proportion to their needs. Improved continuity of healthcare over time could contribute to addressing these needs. General Practitioners need to be able to support people with complex social and medical problems, even in systems that are not specifically designed to manage individuals with such degrees of complexity. We aimed to examine offenders’ perspectives on factors that contributed to, or worked against, creating and sustaining their access to healthcare. Methods: From a sample of 200 participants serving community or prison sentences in South West (SW) and South East (SE) England, who were interviewed about their health care experiences as part of the Care for Offenders: Continuity of Access (COCOA) study, we purposively sampled 22 participants for this sub-study, based on service use. These interviews were transcribed verbatim. A thematic analytic approach initially applied 5 a priori codes based on access and different components of continuity. Data were then examined for factors that contributed to achieving and disrupting access and continuity. Results: Participants described how their own life situations and behaviours contributed to their problems in accessing healthcare and also identified barriers created by existing access arrangements. They also highlighted how some General Practitioners used their initiative and skills to ‘workaround’ the system, and build positive relationships with them; feeling listened to and building trust were particularly valued, as was clear communication. Limitations faced by General Practitioners included a lack of appropriate services to refer people to, where the offender patients would meet the access criteria, and disagreements regarding medication prescriptions. Conclusions: General Practitioners can make a positive contribution to supporting access to healthcare for an under-served population by facilitating more flexible and less formal access arrangements, by using their relationship skills, and by problem-solving. General Practitioners should recognise their potential to transform people’s experience of healthcare whilst working in imperfect systems, particularly with vulnerable and marginalised groups who have complex medical and social needs. [ABSTRACT FROM AUTHOR]

Background: Problem statement: Care for individuals who are marginalised and have complex needs is poor due to both reduced access and poor continuity. Improved access to treatment requires to improvement to both. Previously access has usually been measured quantitatively while there has been a trend to seeing continuity as an 'experience' encompassing relationship, flexibility and organisation of care. Purpose: To develop a causal model for barriers and facilitators of access to and continuity of healthcare care for individuals with complex needs using data from offenders as an exemplary group. Methods: Design: Mixed-method, exploratory synthesis utilising a Realistic Evaluation framework to describe outcomes of interest (access and continuity)and then examine data streams to identify causal influences. Data: Three related data and analysis streams: quantitative analysis of data about care from structured interviews with 200 offenders ; qualitative (pre-coded and thematic) analysis of 25 offender interviews and three focus groups; and two whole-organisation case studies and six mini 'best-practice' case studies from England. Setting: Health and criminal justice systems covering two local authorities in the south west and south east of England and six additional case study sites. Participants: 200 offenders and 35 practitioners and managers. Results: Healthcare was reported as disrupted, with barriers to access and ongoing care; there was quantitative evidence of continuity for those with substance misuse but not for those with mental health problems. In the new model developed from the data, continuity was conceptualised as a continuation of access with the same practitioner, a different practitioner in the same team, or a different team. In contrast we described how organisational and practitioner factors contribute to both initial and ongoing continuity of access. Services needed well engineered access arrangements as well as to demonstrate they have treatments worth receiving to sceptical clients; initial distrust needed to be overcome with skilful practitioner interactions in order to promote continuity; and organisational integrating functions such as liaison, pathways, data sharing and colocation could all play a part in creating continuity but practitioners need to be empowered to be flexible. Conclusions: Access and continuity are best seen as a continuum. By considering organisational and interpersonal factors that contribute to ongoing access, those who provide and commission care for people with complex conditions and from marginalised communities can use the model to specify practitioner behaviours and service configurations which are likely to be helpful in different contexts. [ABSTRACT FROM AUTHOR]