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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. To examine what changes the 2008 financial crisis produced in the pattern of healthcare corporatisation, and the implications for NPWS theories. 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. 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. 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. • English NHS providers were becoming more corporatised until the 2008 financial crisis. • After that, mechanisms that responsibilized NHS managers still developed. • Those that re-commodified NHS providers did not. • NHS corporatisation partly stalled and its development trajectory changed. • These findings suggest revisions to theories of the new politics of the welfare state. [ABSTRACT FROM AUTHOR]

Good integration of services that aim to reduce avoidable acute hospital bed use by older people requires frontline staff to be aware of service options and access them in a timely manner. In three localities where closer inter-organisational integration was taking place, this research sought patients' perceptions of the care received across and within organisational boundaries. Between February and July 2008, qualitative methods were used to map the care journeys of 18 patients (six from each site). Patient interviews (46) covered care received before, at the time of and following a health crisis. Additional interviews (66) were undertaken with carers and frontline staff. Grounded theory-based approaches showed examples of well-integrated care against a background of underuse of services for preventing health crises and a reliance on 'traditional' referral patterns and services at the time of a health crisis. There was scope to raise both practitioner and patient awareness of alternative care options and to expand the availability and visibility of care 'closer to home' services such as rapid response teams. Concerns voiced by patients centred on the adequacy of arrangements for organising ongoing care, while family members reported being excluded from discussions about care arrangements and the roles they were expected to play. The coordination of care was also affected by communication difficulties between practitioners (particularly across organisational boundaries) and a lack of compatible technologies to facilitate information sharing. Finally, closer organisational integration seemed to have limited impact on care at the patient/practitioner interface. To improve care experienced by patients, organisational integration needs to be coupled with vertical integration within organisations to ensure that strategic goals influence the actions of frontline staff. As they experience the complete care journey, feedback from patients can play an important role in the service redesign agenda. [ABSTRACT FROM AUTHOR]

The English NHS has been repeatedly restructured since 1991. Drawing on multiple case studies in English primary health care from 1998 to 2005 and on (other) published studies, this article uses Therborn's theory of power to make a framework analysis of how these reforms redistributed power between medicine and management in NHS primary care. Legal changes ended the GP monopoly of primary medical care provision and, with greater managerial discretion in NHS spending, allowed more diverse organisational forms of primary care provision to appear, although general practice remained predominant. Changes in managerial and professional ideologies relaxed the restrictions on managerial decisions about general practice. Re-negotiations between the medical profession and the statemostly tended to increase managerial power. Evidence-based medicine has tended to weaken the impersonal sources of medical power. On balance, these events have tended to increase managerial power overmedical practice. They also suggest adjustments to Therborn's conceptualisation of power. [ABSTRACT FROM AUTHOR]

Evidence-based adoption of organizational innovations requires explicit definition of the outcomes the innovations are intended to produce. Implementation theory, however, suggests that organizational innovations are often politicized in the sense that the prospect of implementing them provokes conflicts of interests among the parties affected. Then the intended outcomes of the innovation are liable to be formulated ambiguously, misleadingly or not at all, which makes evidence-based organizational innovation unattainable. Analysis of 61 organizational innovations in nine English NHS primary care trusts suggests that while the majority of innovations were not politicized in this way, a substantial minority were. Innovations whose adoption is motivated by evidence can therefore be differentiated from politicized innovations whose adoption is not so motivated, even when they nevertheless do have evidential support. [ABSTRACT FROM AUTHOR]

Organizations providing public welfare services typically have distinct accountabilities to several parties, and the accountability chains linking these parties are often administered through different governance structures. This article reveals that in primary care in England the accountability chains characterized by different governance structures result in inconsistent levels of accountability. [ABSTRACT FROM AUTHOR]

Nurse-led case management programmes have become increasingly popular over the last 15 years. Countries such as the USA, Canada, Sweden and the Netherlands have long running case management programmes in place for frail elderly people. The Department of Health in England has recently introduced a ‘community matron’ role to provide case management to patients with highly complex long-term conditions; a group that is predominantly comprised of elderly people. Department of Health policy documents do not define the day-to-day role of community matrons but instead describe the objectives and principles of case management for long-term conditions. The aim of this qualitative study was to describe case management from the perspective of patients and carers in order to develop a clearer understanding of how the model is being delivered for patients with long-term conditions. In-depth interviews were conducted with a purposive sample of 72 patients and 52 carers who had experience of case management. Five categories of case management tasks emerged from the data: clinical care, co-ordination of care, education, advocacy and psychosocial support. Psychosocial support was emphasised by both patients and carers, and was viewed as equally important to clinical care. Patient and carer perceptions of case management appear to contrast with descriptions contained in Department of Health guidance, suggesting an ‘implementation surplus’ in relation to the policy. This particularly appears to be the case for psychosocial support activities, which are not described in official policy documents. The provision of significant psychosocial support by community matrons also appears to differentiate the model from most other case management programmes for frail elderly people described in the literature. The findings emphasise the importance of seeking patient and carer input when designing new case management programmes. [ABSTRACT FROM AUTHOR]

In this article, the authors discuss the role of action research in relation to the investigation and practical implementation of innovations in health care. The diffusion of innovations is an essential component of the modernization of health services worldwide. However, the literature shows that it is not an easy process to research. A paradox is noted that although action research has much to otter, it has had only a limited impact in the innovation field. Drawing on an example of a project in the United Kingdom, the authors discuss whether action research is a valuable method in the study of the diffusion of innovations. They analyze its strengths and limitations as a "whole systems approach" that combines researching with developing and diffusing innovations. They argue that it is best suited to the study of innovation diffusion where there is a need for high level of adaptation in each new setting. [ABSTRACT FROM AUTHOR]

Objectives To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people. Design Practice level before and after analysis of hospital admissions data with control group. Setting Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission. Main outcome measures Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out). Results The intervention had no significant effect on rates of emergency admission (increase 16.5%, 95% confidence interval -5.7% to 38.7%), emergency bed days (increase 19.0%, -5.3% to 43.2%), and mortality (increase 34.4%, -1.7% to 70.3%) fora high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged >65 effects on the rates of emergency admission (increase 2.5%, -2.1% to 7.0%), emergency bed days (decrease -4.9%, -10.8% to 1.0%), and mortality (increase 5.5%, -3.5% to 14.5%) were also non-significant. Conclusions Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions. [ABSTRACT FROM AUTHOR]

Objective The publication of information about the performance of health-care providers is regarded as central to promoting greater accountability and empowering patients to exercise choice. The evidence suggests that the public is not very interested in accessing or using current sources of information. This study aimed to explore the information needs of patients in the context of UK primary care and to develop an information source about general practice services, designed to be usable by and useful to patients. Design An action research study making use of data from formal and informal interviews, focus groups, participant observation and document review. Setting The geographical areas covered by two Primary Care Trusts in the north of England and two Local Health Boards in south Wales. Participants A partnership between 103 members of the public, general practice staff from 19 practices, NHS managers from four Primary Care Organizations and the research team. Results The public would like to know more about the quality and range of general practice services but current sources of information do not meet their needs. The public do not like league tables comparing the performance of practices and only a small number of people want to use comparative information to choose between practices. They seem to be more interested in the context and availability of services and the willingness of practices to improve, than in the practice's absolute or relative performance. They want to be clear about the source of the information so that they can make personal judgements about its veracity. Information is most likely to be useful if it adheres to the basic principles of cognitive science in terms of its structure, content and presentation format. Using these findings, paper and electronic prototype versions of a guide to general practice services have been developed. Conclusions In order to maximize the potential use of performance information by the public it is necessary to move beyond provider-led and professionally constructed approaches to information provision and ensure that the public is actively involved in the development of information sources. Such involvement produces a different kind of information to that currently available to the public. The findings of this study have important implications for policy. Most importantly, it seems that the traditional consumerist model underlying a policy of making comparative performance information available to the public to enable them to exercise choice between primary care providers may not be appropriate. An alternative model of information provision, which recognizes the public's commitment to their practice and is integrated with ‘soft’ sources of knowledge is more likely to engage and be of use to the public. [ABSTRACT FROM AUTHOR]

Background: This paper outlines the principal characteristics of a learning organisation and the organisational features that define it. It then compares these features with the organisational conditions that currently obtain, or are being created, within the British NHS. The contradictory development of recent British health policy, resulting in the NHS becoming both more marketised and more bureaucratised has correspondingly ambiguous implications for attempts to implement a 'learning organisation' model. Methods: Texts that define and debate the characteristics of a learning organisation were found by snowballing references from the founding learning organisation books and published papers, and then by searching a database specifically devised for a literature review on organisational structures and processes in health care. COPAC and ABI-Info databases for subsequent peer-reviewed publications that also appeared relevant to the present study were searched. Results: The outcomes of the above search are summarised and mapped onto the current constituent organisations of the NHS to identify the extent to which they achieve or approximate to a learning organisation status. Conclusion: Because of the complexity of the NHS and the contradictory processes of marketisation and bureaucratisation characterising it, it cannot, as a whole system, become a learning organisation. However, it is possible that its constituent organisations may achieve this status to varying degrees. Constraints upon NHS managers to speak their minds freely place an ultimate limit on learning organisation development. This limitation suggests that current British health service policy encourages organisational learning-but not too openly and not too much. [ABSTRACT FROM AUTHOR]

This paper reports the findings of a study concerned with the way in which Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) engaged with the Mental Health National Service Framework (NSF) as part of their remit to implement clinical governance. A qualitative multiple case study is reported which used semi-structured interviews and documentary analysis in a purposive sample of 12 PCG-Ts in England. The study found a general awareness of and support for the Mental Health NSF among PCG-Ts. In some localities the NSF acted to reinforce existing local developments in primary care mental health. However, compared to the NSF for Coronary Heart Disease a number of difficulties in responding to the Mental Health NSF were identified. These related to the perceived clinical status and complexity of managing mental health problems at practice level (e.g. familiarity with and competence of General Practitioners (GPs) in managing the conditions), inter-agency working, clinical governance training and the feasibility of producing clear demonstrable mental health outcomes as part of performance management. While the NSF for mental health presents opportunities for establishing the principles of quality assurance and improvement in the area of mental health, it is in danger of being marginalized in the clinical governance agendas of new PCTs, because of an inability to compete on an equal footing with other clinical priorities. While the partial demedicalisation of mental health is increasingly recognised as desirable for policy and therapeutic reasons the corollary is that it is harder to implement non-medicalised forms of care through the essentially medicalised apparatus of clinical governance. In order to deal with the complexities and challenges posed by the mental health agenda targeted support and resources are needed to promote clinical governance developments within primary care organisations. [ABSTRACT FROM AUTHOR]

Current English policy towards general practice is ambivalent between developing new forms of contractual governance and constructing more hierarchically organized bodies. NHS policy documents say that Primary Care Trusts (PCTs) will contract some primary care services and directly manage others. Depending on the balance, PCTs could either organize general practice through practice-based contracts or start developing into hierarchies (albeit with some subcontractors for the time being). New Institutional Economics, in particular Williamson's version, defines conditions where hierarchies are likely to be more efficient than markets (in terms of what welfare economics recognizes as allocative efficiency) and conditions where the reverse holds. This article considers the implications of the New Institutional Economics (NIE) for redesigning the governance of publicly financed services such as general practice which allow direct public access, in which it is difficult to define and manage service quality, and which have a professionalized but fragmented workforce. In contrast to their alleged implications for the hospital sector during the 1990s, NIE theories imply that for publicly funded professional services such as general practice there are stronger economic arguments for constructing hierarchies than for reconstructing quasi-markets at local level. [ABSTRACT FROM AUTHOR]

The implications of the 1997 (Primary Care) Act have been largely overlooked in the rush to establish Primary Care Groups. Allowing health authorities to develop local contracts for primary care has far-reaching implications and is an important departure from the national system of negotiation that has characterized general practice to date. This paper describes a content analysis of a sample of Personal Medical Services (PMS) pilot contracts. In the first year little attention has been given to achieving cost savings or greater efficiency and few contracts promote clinical guidelines. The difficulties of specifying services sensitive to local health needs are highlighted and the national Statement of Fees and Allowances (the 'Red Book') may not be swiftly supplanted. However, The pilots have introduced innovations such as salaried general practitioners, nurse-led services and NHS trust-managed care. The development of local contracts provides a valuable learning experience for general practitioners and health authorities in advance of the establishment of Primary Care Trusts. [ABSTRACT FROM PUBLISHER]

With the implementation of an internal market in the UK National Health Service (NHS), interest in marketing NHS services is growing. Yet marketing practice in other sectors of the economy, and the experience of other markets in health care, raise doubts and objections as to whether marketing should be introduced in the NHS at all. Some of these objections have force, and there are important structural differences between the NHS internal market and conventional markets. Simply copying conventional marketing methods is therefore unlikely to be an effective, or even a desirable, approach to marketing in the NHS. Specific forms of marketing are required for the NHS and these forms differ for purchasing organizations, for commercialized health care providers (including NHS trusts), and for directly-managed NHS services. Differences between these variants can be illustrated by considering the different ways in which a generic model of marketing would have to be amended for each case. The differences also suggest some policy and managerial parameters for the future development of NHS marketing. [ABSTRACT FROM AUTHOR]

Examines the developments of the marketing reforms in much of the public sector in Great Britain with the introduction of the new public management, focusing on the national housing system (NHS). Analysis of the NHS board members's substantive ethical values; What the results of the analysis suggest; Discussion and conclusion of the analysis.

Background: Access times for, the costs and overload of hospital services are an increasingly salient issue for healthcare managers in many countries. Rising demand for hospital care has been attributed partly to unplanned admissions for older people, and among these partly to the increasing prevalence of dementia. The paper makes a preliminary evaluation of the logic model of a Dementia Learning Community (DLC) intended to reduce unplanned hospital admissions from care homes of people with dementia. A dementia champion in each DLC care home trained other staff in dementia awareness and change management with the aims of changing work routines, improving quality of life, and reducing demands on external services.Methods: Controlled mixed methods realistic evaluation comparing 13 intervention homes with 10 controls in England during 2013-15. Each link in the assumed logic model was tested to find whether that link appeared to exist in the DLC sites, and if so whether its effects appeared greater there than in control sites, in terms of selected indicators of quality of life (DCM Well/Ill-Being, QUALID, end-of-life planning); and impacts on ambulance call-outs and hospital admissions.Results: The training was implemented as planned, and triggered cycles of Plan-Do-Study-Act activity in all the intervention care homes. Residents' well-being scores, measured by dementia care mapping, improved markedly in half of the intervention homes but not in the other half, where indeed some scores deteriorated markedly. Most other care quality indicators studied did not significantly improve during the study period. Neither did ambulance call-out or emergency hospital admission rates.Conclusions: PDSA cycles appeared to be the more 'active ingredient' in this intervention. The reasons why they impacted on well-being in half of the intervention sites, and not the others, require further research. A larger, longer study would be necessary to measure definitively any impacts on unplanned hospital admissions. Our evidence suggested revising the DLC logic model to include care planning and staff familiarisation with residents' personal histories and needs as steps towards improving residents' quality of life. [ABSTRACT FROM AUTHOR]

Background: Fragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable 'blue print' mean that services are 'experimenting' with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings., Methods: Two centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations., Results: Extensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the exchange of services and interactions. If collaborative action can foster P3C it will require sustained commitment from both research and practice. This approach is a radical departure from how policy, research and practice traditionally work, but one that we argue is now necessary to deal with the most complex health and social problems.

Background: It is commony claimed that changing the culture of health organisations is a fundamental prerequisite for improving the National Health Service (NHS). Little is currently known about the nature or importance of culture and cultural change in primary care groups and trusts (PCG/Ts) or their constituent general practices., Aims: To investigate the importance of culture and cultural change for the implementation of clinical governance in general practice by PCG/Ts, to identify perceived desirable and undesirable cultural attributes of general practice, and to describe potential facilitators and barriers to changing culture., Design: Qualitative: case studies using data derived from semi-structured interviews and review of documentary evidence., Setting: Fifty senior non-clinical and clinical managers from 12 purposely sampled PCGs or trusts in England., Results: Senior primary care managers regard culture and cultural change as fundamental aspects of clinical governance. The most important desirable cultural traits were the value placed on a commitment to public accountability by the practices, their willingness to work together and learn from each other, and the ability to be self-critical and learn from mistakes. The main barriers to cultural change were the high level of autonomy of practices and the perceived pressure to deliver rapid measurable changes in general practice., Conclusions: The culture of general practice is perceived to be an important component of health system reform and quality improvement. This study develops our understanding of a changing organisational culture in primary care; however, further work is required to determine whether culture is a useful practical lever for initiating or managing improvement.