Implementing changes to hospital services: factors influencing the process and 'results' of reconfiguration

Are acute hospital trust mergers associated with improvements in the quality of care?

PURPOSE

This study aims to assess the extent to which acute hospital trust mergers in England are associated with quality improvements.

DESIGN/METHODOLOGY/APPROACH

We apply an event study design using difference-in-difference (DID) and coarsened exact matching to compare the before-and-after performance of eight mergers from 2011 to 2015.

FINDINGS

We find little evidence that mergers contribute to quality improvements other than some limited increases in the proportion of patients waiting a maximum of 18 weeks from referral to treatment. We postulate that financial incentives and political influence could have biased management effort towards waiting time measures.

RESEARCH LIMITATIONS/IMPLICATIONS

Inherent sample size constraints may limit generalisability. Merger costs and complexity mean they are unlikely to offer an efficient strategy for helping to clear elective care backlogs. We recommend further research into causal mechanisms to help health systems maximise benefits from both mergers and emerging models of hospital provider collaboration.

ORIGINALITY/VALUE

This paper is the first to study the quality impact of a new wave of acute hospital mergers taking place in the English National Health Service from 2011 onwards, applying a group-time DID estimator to account for multiple treatment timings.

A matter of (good) faith? Understanding the interplay of power and the moral agency of managers in healthcare service reconfiguration

Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency - specifically their commitment to patient care - in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs.

Reasons for merging and collaborating in healthcare: Marriage or living apart together?

BACKGROUND

Across OECD countries, integration between healthcare organisations has become an indispensable part of contemporary healthcare provision. In recent years, inter-organisational collaboration has increasingly been encouraged in health and competition policy at the expense of mergers. Yet, understanding of whether healthcare organisations make an active choice between merging and collaborating is lacking. Hence, this study systematically examines (i) healthcare executives' motives for integration, (ii) their potential trade-offs between collaborating or merging, and (iii) the barriers to collaborating perceived by them.

METHODS

Early 2019, an online questionnaire was conducted among a nationwide panel of 714 healthcare executives in the Netherlands. Because of their strategic position within healthcare organisations as end-responsible managers, healthcare executives are especially suited to provide broad and in-depth knowledge on the internal and external processes and decisions. Three hundred thirty-seven Dutch healthcare executives completed the questionnaire (response rate 47%). This study sample was representative of the largest healthcare sectors in the Netherlands. In total, 137 mergers and 235 inter-organisational collaborations were reported. Both closed questions and open-ended questions were systematically analysed.

RESULTS

Improving or broadening healthcare provision is the foremost motive for mergers as well as inter-organisational collaborations. When considering both types, reducing governance complexity is one of the decisive reasons to opt for a merger, whereas aversion towards a full merger and lack of support base within the own organisation convinced healthcare executives to choose for a collaboration. When comparing specific healthcare sectors, the overlap in pursued motives and sub-motives indicates that inter-organisational collaborations and mergers are used for comparable objectives. Only a small minority of the responding executives switched between both types of integration. Institutional barriers, such as laws, regulations and financing regimes, appear to be the most restricting for healthcare executives to engage in inter-organisational collaborations.

CONCLUSIONS

Our integral approach and systematic comparison across sectors could serve policymakers, regulators and healthcare providers in aligning organisational objectives and societal objectives in decision-making on collaborations and mergers. Future research is recommended to study multiple collaboration and merger cases qualitatively for a detailed examination of decision-making by healthcare executives, and develop an integral assessment framework for balancing collaborations and mergers based on their effects in the medium to long term.

The Pervasiveness of Power: Dilemmas for Researchers of Major System Change in Healthcare Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration"

To study major system change (MSC) in healthcare, it is crucial to consider the influence of power. Despite this, dominant perspectives on MSC in healthcare present these as relatively neutral processes, where reconfigurations are logical solutions to clearly defined problems. Perry and colleagues' paper adds to a growing body of research which challenges the presentation of MSC as neutral, managerial processes, instead identifying how power dynamics lie at the heart of why service change happens, how it unfolds, and its outcomes. However, the introduction of power considerations raises several overlapping methodological and ethical dilemmas for researchers, and questions regarding research design and dissemination. In this commentary, we use the insights generated by Perry et al to further explore these issues.

Cost-Utility Analysis of Major System Change in Specialist Cancer Surgery in London, England, Using Linked Patient-Level Electronic Health Records and Difference-in-Differences Analysis

BACKGROUND

Studies have shown that centralising surgical treatment for some cancers can improve patient outcomes, but there is limited evidence of the impact on costs or health-related quality of life.

OBJECTIVES

We report the results of a cost-utility analysis of the RESPECT-21 study using difference-in-differences, which investigated the reconfiguration of specialist surgery services for four cancers in an area of London, compared to the Rest of England (ROE).

METHODS

Electronic health records data were obtained from the National Cancer Registration and Analysis Service for patients diagnosed with one of the four cancers of interest between 2012 and 2017. The analysis for each tumour type used a short-term decision tree followed by a 10-year Markov model with 6-monthly cycles. Costs were calculated by applying National Health Service (NHS) Reference Costs to patient-level hospital resource use and supplemented with published data. Cancer-specific preference-based health-related quality-of-life values were obtained from the literature to calculate quality-adjusted life-years (QALYs). Total costs and QALYs were calculated before and after the reconfiguration, in the London Cancer (LC) area and in ROE, and probabilistic sensitivity analysis was performed to illustrate the uncertainty in the results.

RESULTS

At a threshold of £30,000/QALY gained, LC reconfiguration of prostate cancer surgery services had a 79% probability of having been cost-effective compared to non-reconfigured services using difference-in-differences. The oesophago-gastric, bladder and renal reconfigurations had probabilities of 62%, 49% and 12%, respectively, of being cost-effective at the same threshold. Costs and QALYs per surgical patient increased over time for all cancers across both regions to varying degrees. Bladder cancer surgery had the smallest patient numbers and changes in costs, and QALYs were not significant. The largest improvement in outcomes was in renal cancer surgery in ROE, making the relative renal improvements in LC appear modest, and the probability of the LC reconfiguration having been cost-effective low.

CONCLUSIONS

Prostate cancer reconfigurations had the highest probability of being cost-effective. It is not clear, however, whether the prostate results can be considered in isolation, given the reconfigurations occurred simultaneously with other system changes, and healthcare delivery in the NHS is highly networked and collaborative. Routine collection of quality-of-life measures such as the EQ-5D-5L would have improved the analysis.

UK Healthcare Workers' Experiences of Major System Change in Elective Surgery During the COVID-19 Pandemic: Reflections on Rapid Service Adaptation

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC).

METHODS

Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings.

RESULTS

Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started.

CONCLUSION

Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.

How to Cost the Implementation of Major System Change for Economic Evaluations: Case Study Using Reconfigurations of Specialist Cancer Surgery in Part of London, England

BACKGROUND

Studies have been published regarding the impact of major system change (MSC) on care quality and outcomes, but few evaluate implementation costs or include them in cost-effectiveness analysis (CEA). This is despite large potential costs of MSC: change planning, purchasing or repurposing assets, and staff time. Implementation costs can influence implementation decisions. We describe our framework and principles for costing MSC implementation and illustrate them using a case study.

METHODS

We outlined MSC implementation stages and identified components, using a framework conceived during our work on MSC in stroke services. We present a case study of MSC of specialist surgery services for prostate, bladder, renal and oesophagogastric cancers, focusing on North Central and North East London and West Essex. Health economists collaborated with qualitative researchers, clinicians and managers, identifying key reconfiguration stages and expenditures. Data sources (n = approximately 100) included meeting minutes, interviews, and business cases. National Health Service (NHS) finance and service managers and clinicians were consulted. Using bottom-up costing, items were identified, and unit costs based on salaries, asset costs and consultancy fees assigned. Itemised costs were adjusted and summed.

RESULTS

Cost components included options appraisal, bidding process, external review; stakeholder engagement events; planning/monitoring boards/meetings; and making the change: new assets, facilities, posts. Other considerations included hospital tariff changes; costs to patients; patient population; and lifetime of changes. Using the framework facilitated data identification and collection. The total adjusted implementation cost was estimated at £7.2 million, broken down as replacing robots (£4.0 million), consultancy fees (£1.9 million), staff time costs (£1.1 million) and other costs (£0.2 million).

CONCLUSIONS

These principles can be used by funders, service providers and commissioners planning MSC and researchers evaluating MSC. Health economists should be involved early, alongside qualitative and health-service colleagues, as retrospective capture risks information loss. These analyses are challenging; many cost factors are difficult to identify, access and measure, and assumptions regarding lifetime of the changes are important. Including implementation costs in CEA might make MSC appear less cost effective, influencing future decisions. Future work will incorporate this implementation cost into the full CEAs of the London Cancer MSC.

TRIAL REGISTRATION

Not applicable.

Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation

BACKGROUND

Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel.

OBJECTIVE

The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals.

METHODS

This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test.

RESULTS/FINDINGS

Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]).

CONCLUSIONS

High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.

Organisational development to support integrated care in East London: the perspective of clinicians and social workers on the ground

PURPOSE

Organisational Development (OD), with its focus on partnership working and distributed leadership, is increasingly advocated as an effective approach to driving change. Our evaluation of the impact of OD on delivery of integrated care in three London boroughs sheds light on how OD is being understood and implemented within health services, and what impact it is having on delivery of care.

DESIGN/METHODOLOGY/APPROACH

The findings presented here are based on a qualitative and participatory evaluation. The authors looked at how health and social care professionals communicated and coordinated delivery of care and evaluated the impact of current OD activities on the ground to evidence whether and to which degree they are enabling frontline staff to change their working routines towards greater coordination.

FINDINGS

Our findings highlight the limited reach and scope of a top-down approach to OD based on ad hoc coaching and staff engagement events, often delivered by external consultancies, and mostly focused at the senior management level. This approach fell short of enabling the creation of sustainable, integrated and collaborative organisations. Instead, some of the professionals that participated in our study tried to develop spaces that facilitated ongoing dialogue and mutual support among professionals on the ground.

PRACTICAL IMPLICATIONS

Initiatives of bottom-up OD such as those described in this paper have greater potential to change working routines as they enable staff to move towards more collaborative and coordinated work.

ORIGINALITY/VALUE

These findings contribute to the literature on OD in public services and highlight the benefits of a context-sensitive, pragmatic, and long-term approach to OD to help create sustainable collaborative organisations.

Does admission prevalence change after reconfiguration of inpatient services? An interrupted time series analysis of the impact of reconfiguration in five centres

Background

Service reconfiguration of inpatient services in a hospital includes complete and partial closure of all emergency inpatient facilities. The “natural experiment” of service reconfiguration may give insight into drivers for emergency admissions to hospital. This study addressed the question does the prevalence of emergency admission to hospital for children change after reconfiguration of inpatient services?

Methods

There were five service reconfigurations in Scottish hospitals between 2004 and 2018 where emergency admissions to one “reconfigured” hospital were halted (permanently or temporarily) and directed to a second “adjacent” hospital. The number of emergency admissions (standardised to /1000 children in the regional population) per month to the “reconfigured” and “adjacent” hospitals was obtained for five years prior to reconfiguration and up to five years afterwards. An interrupted time series analysis considered the association between reconfiguration and admissions across pairs comprised of “reconfigured” and “adjacent” hospitals, with adjustment for seasonality and an overall rising trend in admissions.

Results

Of the five episodes of reconfiguration, two were immediate closure, two involved closure only to overnight admissions and one with overnight closure for a period and then closure. In “reconfigured” hospitals there was an average fall of 117 admissions/month [95% CI 78, 156] in the year after reconfiguration compared to the year before, and in “adjacent” hospitals admissions rose by 82/month [32, 131]. Across paired reconfigured and adjacent hospitals, in the months post reconfiguration, the overall number of admissions to one hospital pair slowed, in another pair admissions accelerated, and admission prevalence was unchanged in three pairs. After reconfiguration in one hospital, there was a rise in admissions to a third hospital which was closer than the named “adjacent” hospital.

Conclusions

There are diverse outcomes for the number of emergency admissions post reconfiguration of inpatient facilities. Factors including resources placed in the community after local reconfiguration, distance to the “adjacent” hospital and local deprivation may be important drivers for admission pathways after reconfiguration. Policy makers considering reconfiguration might consider a number of factors which may be important determinants of admissions post reconfiguration.

Changing health care with, for, or against the public: an empirical investigation into the place of the public in health service reconfiguration

OBJECTIVES

This study sought to understand the different approaches taken to involving the public in service reconfiguration in the four United Kingdom health systems.

METHODS

This was a multi-method study involving policy document analysis and qualitative semi-structured interviews in England, Northern Ireland, Scotland and Wales.

RESULTS

Despite the diversity of local situations, interview participants tended to use three frames within which they understood the politics of service reconfigurations: an adversarial approach which assumed conflict over scarce resources (change against the public); a communications approach which defined the problem as educating the public on the desirability of change (change for the public); and a collaborative approach which attempted to integrate the public early into discussions about the shape and nature of desirable services (change with the public). These three framings involved different levels of managerial time, energy, and resources and called on different skill sets, most notably marketing and communications for the communications approach and community engagement for the collaborative approach.

CONCLUSIONS

We argue that these framings of public involvement co-exist within organisations. Health system leaders, in framing service reconfiguration as adversarial, communicative or collaborative, are deciding between conceptions of the relationship between health care organisations and their publics in ways that shape the nature of the debates that follow. Understanding the reasons why organisations adopt these frames would be a fruitful way to advance both theory and practice.

Social movements and the contested institutional identity of the hospital

Taking popular protest as a common reaction to changes in hospital services as its point of departure, this paper explores how a social movement has taken on the issue of the hospital as an institution. In the wake of the transformation of Norwegian public hospitals into health enterprises (trusts), this paper explores community resistance to the proposals and plans of decision-makers to restructure hospitals. The study is based on a qualitative and quantitative analysis of the website/blog for the local hospital movement's activities from 2007 until 2017 and of its involvement and resistance in respect of three instances of proposed change to the hospital structure during this period. The study reveals that the health enterprises and the managerialism they represent pose a threat to individual safety and sense of belonging, and to the preservation and identity of the local community. Moreover, the framing of the cause of the local hospital movement illuminates how the institutional identity of the hospital is highly contested between the institutional categories of 'public administration' on the one hand, and 'the company' on the other. The impact of the local hospital movement has proven modest in terms of influencing and reversing decisions to restructure hospitals, but it has been considerable in terms of cultural support for its concepts and values, not just concerning hospitals and health care services, but also with regard to democratic governance.

(Dis)Integrated Care? Lessons from East London

INTRODUCTION

This paper examines one of the NHS England Pioneers programmes of Integrated Care, which was implemented in three localities in East London, covering the area served by one of the largest hospital groups in the UK and bringing together commissioners, providers and local authorities. The partners agreed to build a model of integrated care that focused on the whole person. This qualitative and participatory evaluation looked at how an ambitious vision translated into the delivery of integrated care on the ground. The study explored the micro-mechanisms of integrated care relationships based on the experience of health and social care professionals working in acute and community care settings.

METHODS

We employed a participatory approach, the Researcher in Residence model, whereby the researcher was embedded in the organisations she evaluated and worked alongside managers and clinicians to build collaboration across the full range of stakeholders, develop shared learning, and find common ground through competing interests, while trying to address power imbalances. A number of complementary qualitative methods of data generation were used, including documentary analysis, participant observations, semi-structured interviews, and coproduction workshops with frontline health and social care professionals to interpret the data and develop recommendations.

RESULTS

Our fieldwork exposed persistent organisational fragmentation, despite the dominant rhetoric of integration and efforts to build a shared vision at senior governance levels. The evaluation identified several important themes, including: a growing barrier between acute and community services; a persisting difficulty experienced by health and social care staff in working together because of professional and cultural differences, as well as conflicting organisational priorities and guidelines; and a lack of capacity and support to deliver a genuine multidisciplinary approach in practice, despite the ethos of multiagency being embraced widely.

DISCUSSION

By focusing on professionals' working routines, we detailed how and why action taken by organisational leaders failed to have tangible impact. The inability to align organisational priorities and guidelines on the ground, as well as a failure to acknowledge the impact of structural incentives for organisations to compete at the expense of cooperation, in a context of limited financial and human resources, acted as barriers to more coordinated working. Within an environment of continuous reconfigurations, staff were often confused about the functions of new services and did not feel they had influence on change processes. Investing in a genuine bottom-up approach could ensure that the range of activities needed to generate system-wide cultural transformation reflect the capacity of the organisations and systems and address genuine local needs.

LIMITATIONS

The authors acknowledge several limitations of this study, including the focus on one geographical area, East London, and the timing of the evaluation, with several new interventions and programmes introduced more or less simultaneously. Some of the intermediate care services under evaluation were still at pilot stage and some teams were undergoing new reconfigurations, reflecting the fast-pace of change of the past decade. This created confusion at times, for instance when discussing specific roles and activities with participants. We tried to address some of these challenges by organising several workshops with different teams to co-interpret and discuss the findings.

Transforming health care: the policy and politics of service reconfiguration in the UK's four health systems

Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used 'sticks' and 'sermons' to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.

A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland's hospitals

BACKGROUND

To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation.

METHODS

We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation.

DISCUSSION

This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

Implementing a toolkit for the prevention, management and control of carbapenemase-producing Enterobacteriaceae in English acute hospitals trusts: a qualitative evaluation

BACKGROUND

Antimicrobial resistance is an increasing problem in hospitals world-wide. Following other countries, English hospitals experienced outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), a bacterial infection commonly resistant to last resort antibiotics. One way to improve CPE prevention, management and control is the production of guidelines, such as the CPE toolkit published by Public Health England in December 2013. The aim of this research was to investigate the implementation of the CPE toolkit and to identify barriers and facilitators to inform future policies.

METHODS

Acute hospital trusts (N = 12) were purposively sampled based on their self-assessed CPE colonisation rates and time point of introducing local CPE action plans. Following maximum variation sampling, 44 interviews with hospital staff were conducted between April and August 2017 using a semi-structured topic guide based on the Capability, Opportunity, Motivation and Behaviour Model and the Theoretical Domains Framework, covering areas of influences on behaviour. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

The national CPE toolkit was widely disseminated within infection prevention and control teams (IPCT), but awareness was rare among other hospital staff. Local plans, developed by IPCTs referring to the CPE toolkit while considering local circumstances, were in place in all hospitals. Implementation barriers included: shortage of isolation facilities for CPE patients, time pressures, and competing demands. Facilitators were within hospital and across-hospital collaborations and knowledge sharing, availability of dedicated IPCTs, leadership support and prioritisation of CPE as an important concern. Participants using the CPE toolkit had mixed views, appreciating its readability and clarity about patient management, but voicing concerns about the lack of transparency on the level of evidence and the practicality of implementation. They recommended regular updates, additional clarifications, tailored information and implementation guidance.

CONCLUSIONS

There were problems with the awareness and implementation of the CPE toolkit and frontline staff saw room for improvement, identifying implementation barriers and facilitators. An updated CPE toolkit version should provide comprehensive and instructive guidance on evidence-based CPE prevention, management and control procedures and their implementation in a modular format with sections tailored to hospitals' CPE status and to different staff groups.

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.

A sociology of public responses to hospital change and closure

The "problem" of public resistance to hospital closure is a recurring trope in health policy debates around the world. Recent papers have argued that when it comes to major change to hospitals, "the public" cannot be persuaded by clinical evidence, and that mechanisms of public involvement are ill-equipped to reconcile opposition with management desire for radical change. This paper presents data from in-depth qualitative case studies of three hospital change processes in Scotland's National Health Service, including interviews with 44 members of the public. Informed by sociological accounts of both hospitals and publics as heterogeneous, shifting entities, I explore how hospitals play meaningful roles within their communities. I identify community responses to change proposals which go beyond simple opposition, including evading, engaging with and acquiescing to changes. Explicating both hospitals and the publics they serve as complex social phenomena strengthens the case for policy and practice to prioritise dialogic processes of engagement. It also demonstrates the continuing value of careful, empirical research into public perspectives on contentious healthcare issues in the context of everyday life.

Understanding the impetus for major systems change: A multiple case study of decisions and non-decisions to reconfigure emergency and urgent care services

OBJECTIVE

The optimal organisation of emergency and urgent care services (EUCS) is a perennial problem internationally. Similar to other countries, the Health Service Executive in Ireland pursued EUCS reconfiguration in response to quality and safety concerns, unsustainable costs and workforce issues. However, the implementation of reconfiguration has been inconsistent at a regional level. Our aim was to identify the factors that led to this inconsistency.

METHODS

Using a multiple case study design, six case study regions represented full, partial and little/no reconfiguration at emergency departments (EDs). Data from documents and key stakeholder interviews were analysed using a framework approach with cross-case analysis.

RESULTS

The impetus to reconfigure ED services was triggered by patient safety events, and to a lesser extent by having a region-specific plan and an obvious starting point for changes. However, the complexity of the next steps and political influence impeded reconfiguration in several regions. Implementation was more strategic in regions that reconfigured later, facilitated by clinical leadership and "lead-in time" to plan and sell changes.

CONCLUSION

While the global shift towards centralisation of EUCS is driven by universal challenges, decisions about when, where and how much to implement are influenced by local drivers including context, people and politics. This can contribute to a public perception of inequity and distrust in proposals for major systems change.

Biopolitics, space and hospital reconfiguration

Major service change in healthcare - whereby the distribution of services is reconfigured at a local or regional level - is often a contested, political and poorly understood set of processes. This paper contributes to the theoretical understanding of major service change by demonstrating the utility of interpreting health service reconfiguration as a biopolitical intervention. Such an approach orients the analytical focus towards an exploration of the spatial and the population - crucial factors in major service change. Drawing on a qualitative study from 2011-12 of major service change in the English NHS combining documentary analyses of historically relevant policy papers and contemporary policy documentation (n = 125) with semi-structured interviews (n = 20) we highlight how a particular 'geography of stroke' in London was created building upon multiple types of knowledge: medical, epidemiological, economic, demographic, managerial and organisational. These informed particular spatial practices of government providing legitimation for the significant political upheaval that accompanies NHS service reconfiguration by problematizing existing variation in outcomes and making these visible. We suggest that major service change may be analysed as a 'practice of security' - a way of redefining a case, conceiving of risks and dangers, and averting potential crises in the interests of the population.

Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study

Background

Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.

Objective

To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.

Design

Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.

Results

Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.

Limitations

The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.

Conclusions

Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Costs will rather increase

Purpose

The purpose of this paper was to study the unfolding of an urgent and extensive decommissioning program in Sweden, focusing on the public’s reactions and their arguments when opposing the decommissioning activities.

Design/methodology/approach

The public’s responses were studied through local media. Its content was surveyed and divided into actions and arguments. The arguments were further analyzed and categorized into inductively developed themes.

Findings

Protest activities, such as demonstrations, meetings and petitions, were not coordinated, but mostly carried out for withdrawals of unique services and services in remote areas. The public questioned the decision makers’ information, calculations and competence, the adequacy of the consequence analyses and whether the decommissioning activities would lead to any real savings. Patient and public safety, the vulnerable in society, and effects on the local areas were important topics. Thus, it seems the decision makers did not fully succeed in communicating the demonstrable benefits or create clarity of the rationales for decommissioning the particular services. Furthermore, it seems the public has a more inclusive approach to health services and their value compared to decision makers that need to keep the budget.

Originality/value

Decommissioning is an emerging field of research, and this study of the unfolding of an urgent and extensive decommissioning program contributes with evidence that may improve decommissioning policy and practice. The study illustrates that it may be possible to implement a decommissioning program despite public protest, but that the longer-term effects on the health system’s legitimacy need to be studied.

Development of a surgical site infection surveillance programme in a Scottish neurosurgical unit

Purpose

Surgical site infection (SSI) is a common complication in surgical practice. SSIs represent almost a fifth of healthcare-associated infections in Scotland, and have deleterious effects on mortality, morbidity, length of stay, and cost to the health service. SSIs in neurosurgery may be more consequential than in other specialities given the potentially devastating effects of central nervous system infection. The paper aims to discuss these issues.

Design/methodology/approach

In 2014, the authors became concerned about an anecdotal increase in infection rates in the authors’ unit. While national guidance on SSI surveillance existed in England and Scotland, the authors had no relevant procedures or policies in Glasgow, and began the process of establishing a surveillance programme. This was driven by clinicians but faced challenges due to a lack of involvement of the wider organisation in the early stages.

Findings

SSIs were initially reported via a form-filling system. This developed into an editable hospital intranet database, but still suffered from the problems of voluntary entries and under-reporting. Following the formal engagement of management structures and the funding of a surveillance nurse, the authors’ programme developed robustness, and resilience. With the advent of an SSI committee, the authors now have a well-established programme that ingrains SSI prevention in the collective learning and organisational memory of the authors’ unit.

Originality/value

Clinicians must lead on the development of these programmes, but long-term durability requires engagement and support from the wider organisation.

Models for governing relationships in healthcare organizations: Some empirical evidence

Recently, most European countries have undergone integration processes through mergers and strategic alliances between healthcare organizations. The present paper examined three cases within the Italian National Health Service in order to determine how different organizations, within differing institutional contexts, govern an healthcare integration process. Furthermore, we explored the possibility that the governance mode, usually seen as alternatives (i.e., merger or alliance), could be considered as a separate step in the development of a more suitable integration process. Multiple case studies were used to compare different integration approaches. Specifically, three cases were considered, of which two were characterized by collaborative processes and the other by a merger. Semi-structured interviews were conducted with managers involved in the processes. Each case presents different governing modes, structures, and mechanisms for achieving integration. The role played by the institutional context also led to different results with unique advantages and disadvantages. Three main conclusions are discussed: (a) Alliances and mergers can be interpreted as different steps in a path leading to a better integration; (b) The alignment between institutional/political time horizon and the time needed for the organizations to achieve an integration process lead to a better integration;

Perspectives on the underlying drivers of urgent and emergency care reconfiguration in Ireland

BACKGROUND

There is an increasing tendency to reconfigure acute hospital care towards a more centralised and specialised model, particularly for complex care conditions. Although centralisation is presented as "evidence-based", the relevant studies are often challenged by groups which hold perspectives and values beyond those implicit in the literature. This study investigated stakeholder perspectives on the rationale for the reconfiguration of urgent and emergency care in Ireland. Specifically, it considered the hypothesis that individuals from different stakeholder groups would endorse different positions in relation to the motivation for, and goals of, reconfiguration.

METHODS

Documentary analysis of policy documents was used to identify official justifications for change. Semi-structured interviews with 175 purposively sampled stakeholders explored their perspectives on the rationale for reconfiguration.

RESULTS

While there was some within-group variation, internal and external stakeholders generally vocalised different lines of argument. Clinicians and management in the internal stakeholder group proposed arguments in favour of reconfiguration based on efficiency and safety claims. External stakeholders, including hospital campaigners and local political representatives expressed arguments that focused on access to care. A "voter" argument, focused on the role of local politicians in determining the outcome of reconfiguration planning, was mentioned by both internal and external stakeholders, often in a critical fashion.

CONCLUSION

Our study adds to an emerging literature on the interaction between a technocratic approach to health system planning advocated by clinicians and health service managers, and the experiential "non-expert" claims of the public and patients.

Major health service transformation and the public voice: conflict, challenge or complicity?

Objectives

Calls for major reconfigurations of health services have been accompanied by recommendations that wide ranging stakeholders be involved. In particular, patients and the wider public are seen as critical contributors as both funders and beneficiaries of public health care. But public involvement is fraught with challenges, and little research has focused on involvement in the health service transformation initiatives. This paper examines the design and function of public involvement in reconfiguration of health services within the English NHS.

Methods

Qualitative data including interviews, observation and documents were collected in two health service ‘transformation’ programmes; interviews include involved public and professional participants. Data were analysed using parallel deductive and inductive approaches.

Results

Public involvement in the programmes was extensive but its terms of reference, and the individuals involved, were restricted by policy pressures and programme objectives. The degree to which participants descriptively or substantively represented the wider public was limited; participants sought to ‘speak for’ this public but their views on what was ‘acceptable’ and likely to influence decision-making led them to constrain their contributions.

Conclusions

Public involvement in two major service reconfiguration programmes in England was seen as important and functional, and could not be characterized as tokenistic. Yet involvement in these programmes fell short of normative ideals, and could inadvertently reduce, rather than enlarge, public influence on health service reconfiguration decisions.

Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study

Background

Decommissioning – defined as the planned process of removing, reducing or replacing health-care services – is an important component of current reforms in the NHS. However, the evidence base on which to guide policy and practice in this area is weak.

Aim

This study aims to formulate theoretically grounded, evidence-informed guidance to support best practice in effective decommissioning of NHS services.

Design

The overall approach is a sequential, multimethod research design. The study involves (1) a literature synthesis summarising what is known about decommissioning, an international expert Delphi study, 12 interviews with national/regional bodies and seven narrative vignettes from NHS leaders; (2) a survey of Clinical Commissioning Groups (CCGs) in England (n = 56/211, 27%); (3) longitudinal, prospective case studies of four purposively sampled decommissioning projects comprising 59 semistructured interviews, 18 non-participant observations and documentary analysis; and (4) research with citizens, patient/service user representatives, carers, third-sector organisations and local community groups, including three focus groups (30 participants) and a second Delphi study (26 participants). The study took place over the period 2013–16.

Setting

The English NHS.

Results

There is a lack of robust evidence to guide decommissioning, but among experts there is a high level of consensus for the following good-practice principles: establish a strong leadership team, engage clinical leaders from an early stage and establish a clear rationale for change. The most common type of CCG decommissioning activity was ‘relocation or replacement of a service from an acute to a community setting’ (28% of all activities) and the majority of responding CCGs (77%) were planning to decommission services. Case studies demonstrate the need to (1) draw on evidence, reviews and policies to frame the problem; (2) build alliances in order to legitimise decommissioning as a solution; (3) seek wider acceptance, including among patients and community groups, of decommissioning; and (4) devise implementation plans that recognise the additional challenges of removal and replacement. Citizens, patient/service user representatives, carers, third-sector organisations and local community groups were more likely to believe that decommissioning is driven by financial and political concerns than by considerations of service quality and efficiency, and to distrust and/or resent decision-makers. Overall, the study suggests that failure rates in decommissioning are likely to be higher than in other forms of service change, suggesting the need for tailored design and implementation approaches.

Limitations

There were few opportunities for patient and public engagement in early phases of the research; however, this was mitigated by the addition of work package 4. We were unable to track outcomes of decommissioning activities within the time scales of the project and the survey response rate was lower than anticipated.

Conclusions

Decommissioning is shaped by change management and implementation, evidence and information, and relationships and politics. We propose an expanded understanding, encompassing organisational and political factors, of how avoidance of loss affects the delivery of decommissioning programmes. Future work should explore the relationships between contexts, mechanisms and outcomes in decommissioning, develop the understanding of how loss affects decisions and explore the long-term impact of decommissioning and its impact on patient care and outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

'Holding the line': a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London

BACKGROUND

Health service reconfigurations are of international interest but remain poorly understood. This article focuses on the use of evidence by senior managerial decision-makers involved in the reconfiguration of stroke services in London 2008-2012. Recent work comparing stroke service reconfiguration in London and Manchester emphasises the ability of senior managerial decision-makers in London to 'hold the line' in the crucial early phases of the stroke reconfiguration programme. In this article, we explore in detail how these decision-makers 'held the line' and ask what the broader power implications of doing so are for the interaction between evidence, health policy and system redesign.

METHODS

The research combined semi-structured interviews (n = 20) and documentary analysis of historically relevant policy papers and contemporary stroke reconfiguration documentation published by NHS London and other interested parties (n = 125). We applied a critical interpretive and reflexive approach to the analysis of the data.

RESULTS

We identified two forms of power which senior managerial decision-makers drew upon in order to 'hold the line'. Firstly, discursive power, which through an emphasis on evidence, better patient outcomes, professional support and clinical credibility alongside a tightly managed consultation process, helped to set an agenda that was broadly receptive to the overall decision to change stroke services in the capital in a radical way. Secondly, once the essential parameters of the decision to change services had been agreed, senior managerial decision-makers 'held the line' through hierarchical New Public Management style power to minimise the traditional pressures to de-radicalise the reconfiguration through 'top down' decision-making.

CONCLUSIONS

We problematise the concept of 'holding the line' and explore the power implications of such managerial approaches in the early phases of health service reconfiguration. We highlight the importance of evidence for senior managerial decision-makers in agenda setting and the limitations of clinical research findings in guiding politically sensitive policy decisions which impact upon regional healthcare systems.

Understanding perspectives on major system change: A comparative case study of public engagement and the implementation of urgent and emergency care system reconfiguration

OBJECTIVES

Major changes have been made to how emergency care services are configured in several regions in the Republic of Ireland. This study investigated the hypothesis that engagement activities undertaken prior to these changes influenced stakeholder perspectives on the proposed changes and impacted on the success of implementation.

METHODS

A comparative case-study approach was used to explore the changes in three regions. These regions were chosen for the case study as the nature of the proposals to reconfigure care provision were broadly similar but implementation outcomes varied considerably. Documentary analysis of reconfiguration planning reports was used to identify planned public engagement activities. Semi-structured interviews with 74 purposively-sampled stakeholders explored their perspectives on reconfiguration, engagement activities and public responses to reconfiguration. Framework analysis was used, integrating inductive and deductive approaches.

RESULTS

Approaches to public engagement and success of implementation differed considerably across the three cases. Regions that presented the public with the reconfiguration plan alone reported greater public opposition and difficulty in implementing changes. Engagement activities that included a range of stakeholders and continued throughout the reconfiguration process appeared to largely address public concerns, contributing to smoother implementation.

CONCLUSIONS

The presentation of reconfiguration reports alone is not enough to convince communities of the case for change. Genuine, ongoing and inclusive engagement offers the best opportunity to address community concerns about reconfiguration.

Patient experience of different regional models of urgent and emergency care: a cross-sectional survey study

OBJECTIVES

To compare user experiences of 8 regional urgent and emergency care systems in the Republic of Ireland, and explore potential avenues for improvement.

DESIGN

A cross-sectional survey.

SETTING

Several distinct models of urgent and emergency care operate in Ireland, as system reconfiguration has been implemented in some regions but not others. The Urgent Care System Questionnaire was used to explore service users' experiences with urgent and emergency care. Linear regression and logistic regression were used to detect regional variation in each of the 3 domains and overall ratings of care.

PARTICIPANTS

A nationally representative sample (N=8002) of the general population was contacted by telephone, yielding 1205 participants who self-identified as having used urgent and emergency care services in the previous 3 months.

MAIN OUTCOME MEASURES

Patient experience was assessed across 3 domains: entry into the system, progress through the system and patient convenience of the system. Participants were also asked to provide an overall rating of the care they received.

RESULTS

Service users in Dublin North East gave lower ratings on the entry into the system scale than those in Dublin South (adjusted mean difference=-0.18; 95% CI -0.35 to -0.10; p=0.038). For overall ratings of care, service users in the Mid-West were less likely than those in Dublin North East to give an excellent rating (adjusted OR 0.57; 95% CI 0.35 to 0.92; p=0.022). Survey items relating to communication, and consideration of patients' needs were comparatively poorly rated. The use of public emergency departments and out-of-hours general practice care was associated with poorer patient experiences.

CONCLUSIONS

No consistent relationship was found between the type of urgent and emergency care model in different regions and patient experience. Scale-level data may not offer a useful metric for exploring the impact of system-level service change.

Transforming community health services for children and young people who are ill: a quasi-experimental evaluation

Background

Children’s community nursing (CCN) services support children with acute, chronic, complex and end-of-life care needs in the community.

Objectives

This research examined the impact of introducing and expanding CCN services on quality, acute care and costs.

Methods

A longitudinal, mixed-methods, case study design in three parts. The case studies were in five localities introducing or expanding services. Part 1: an interrupted time series (ITS) analysis of Hospital Episode Statistics on acute hospital admission for common childhood illness, and bed-days and length of stay for all conditions, including a subset for complex conditions. The ITS used between 60 and 84 time points (monthly data) depending on the case site. Part 2: a cost–consequence analysis using activity data from CCN services and resource-use data from a subset of families (n = 32). Part 3: in-depth interviews with 31 parents of children with complex conditions using services in the case sites and a process evaluation of service change with 41 NHS commissioners, managers and practitioners, using longitudinal in-depth interviews, focus groups and documentary data.

Findings

Part 1: the ITS analysis showed a mixed pattern of impact on acute activity, with the greatest reductions in areas that had rates above the national average before CCN services were introduced and significant reductions in some teams in acute activity for children with complex conditions. Some models of CCN appear to have more potential for impact than others. Part 2: the cost–consequence analysis covered only part of the CCN teams’ activity. It showed some potential savings from reduced admissions and bed-days, but none that was greater than the total cost of the services. Part 3: three localities implemented services as planned, one achieved partial service change and one was not able to achieve any service change. Organisational stability, finance, medical stakeholder support, competition, integration with primary care and visibility influenced the planning and implementation of new and expanded CCN services. Feeling supported to manage their ill child at home was a key outcome of using services for parents. Various service features contributed to this and were important in different ways at different times. Other outcomes included being able to avoid hospital care, enabling the child to stay in school, and getting respite. Although parents judged that care was of high quality when teams enabled them to feel supported, reassured and secure in managing their ill child at home, this did not depend on a constant level of contact from teams.

Limitations

Delays in service reconfigurations required adaptation of research activity across sites. Use of administrative data, such as Hospital Episode Statistics, for research purposes is technically difficult and imposed some limitations on both the ITS and the cost–consequence analyses.

Conclusions

Large, generic CCN teams that integrate acute admission avoidance for all children with support for children with complex conditions and highly targeted teams for children with complex conditions offer the possibility of supporting children more appropriately at home while also making some difference to acute activity. This possibility remains to be tested further.

Future work

Further work should refine the evidence on outcomes of services by looking at outcomes in promising models, value for money and measuring quality-based outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Explaining outcomes in major system change: a qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England

Background

Implementing major system change in healthcare is not well understood. This gap may be addressed by analysing change in terms of interrelated components identified in the implementation literature, including decision to change, intervention selection, implementation approaches, implementation outcomes, and intervention outcomes.

Methods

We conducted a qualitative study of two cases of major system change: the centralisation of acute stroke services in Manchester and London, which were associated with significantly different implementation outcomes (fidelity to referral pathway) and intervention outcomes (provision of evidence-based care, patient mortality). We interviewed stakeholders at national, pan-regional, and service-levels (n = 125) and analysed 653 documents. Using a framework developed for this study from the implementation science literature, we examined factors influencing implementation approaches; how these approaches interacted with the models selected to influence implementation outcomes; and their relationship to intervention outcomes.

Results

London and Manchester’s differing implementation outcomes were influenced by the different service models selected and implementation approaches used. Fidelity to the referral pathway was higher in London, where a ‘simpler’, more inclusive model was used, implemented with a ‘big bang’ launch and ‘hands-on’ facilitation by stroke clinical networks. In contrast, a phased approach of a more complex pathway was used in Manchester, and the network acted more as a platform to share learning. Service development occurred more uniformly in London, where service specifications were linked to financial incentives, and achieving standards was a condition of service launch, in contrast to Manchester. ‘Hands-on’ network facilitation, in the form of dedicated project management support, contributed to achievement of these standards in London; such facilitation processes were less evident in Manchester.

Conclusions

Using acute stroke service centralisation in London and Manchester as an example, interaction between model selected and implementation approaches significantly influenced fidelity to the model. The contrasting implementation outcomes may have affected differences in provision of evidence-based care and patient mortality. The framework used in this analysis may support planning and evaluating major system changes, but would benefit from application in different healthcare contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0445-z) contains supplementary material, which is available to authorized users.

Beyond NIMBYs and NOOMBYs: what can wind farm controversies teach us about public involvement in hospital closures?

Background

Many policymakers, researchers and commentators argue that hospital closures are necessary as health systems adapt to new technological and financial contexts, and as population health needs in developed countries shift. However closures are often unpopular with local communities. Previous research has characterised public opposition as an obstacle to change. Public opposition to the siting of wind farms, often described as NIMBYism (Not In My Back Yard), is a useful comparator issue to the perceived NOOMBYism (Not Out Of My Back Yard) of hospital closure protestors.

Discussion

The analysis of public attitudes to wind farms has moved from a fairly crude characterisation of the ‘attitude-behaviour gap’ between publics who support the idea of wind energy, but oppose local wind farms, to empirical, often qualitative, studies of public perspectives. These have emphasised the complexity of public attitudes, and revealed some of the ‘rational’ concerns which lie beneath protests. Research has also explored processes of community engagement within the wind farm decision-making process, and the crucial role of trust between communities, authorities, and developers.

Summary

Drawing on what has been learnt from studies of opposition to wind farms, we suggest a range of questions and approaches to explore public perspectives on hospital closure more thoroughly. Understanding the range of public responses to service change is an important first step in resolving the practical dilemma of effecting health system transformation in a democratic fashion.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Factors that influence the way local communities respond to consultation processes about major service change: A qualitative study

•

In England, service change proposals often face public opposition.

•

We examined the public response to a consultation process about service reorganisation.

•

The behaviour of key decision-makers led the public to mistrust the process.

•

This was compounded by the complexity of the consultation methods.

•

Future consultations should acknowledge public concerns about proposals.

Objectives

In England, proposed service changes such as Emergency Department closures typically face local opposition. Consequently, public consultation exercises often involve protracted, hostile debates. This study examined a process aimed at engaging a community in decision-making about service reconfiguration, and the public response to this process.

Methods

A documentary analysis was conducted to map consultation methods used in an urban area of England where plans to consolidate hospital services on fewer sites were under discussion. In-depth interviews (n = 20) were conducted with parents, older people, and patient representatives. The analysis combined inductive and deductive approaches, informed by risk communication theories.

Results

The commissioners provided a large volume of information about the changes, alongside a programme of public events. However, the complexity of the process, together with what members of the public perceived to be the commissioners’ dismissal of their concerns, led the community to question their motivation. This was compounded by a widespread perception that the proposals were financially driven.

Discussion

Government policy emphasises the importance of clinical leadership and ‘evidence’ in public consultation. However, an engagement process based on this approach fuelled hostility to the proposals. Policymakers should not assume communities can be persuaded to accommodate service change which may result in reduced access to care.

Factors that influence the way communities respond to proposals for major changes to local emergency services: a qualitative study

OBJECTIVE

According to policy commentators, decisions about how best to organise care involve trade-offs between factors relating to care quality, workforce, cost, and patient access. In England, proposed changes such as Emergency Department closures often face public opposition. This study examined the way communities respond to plans aimed at reorganising emergency services, including the trade-offs inherent in such decisions.

DESIGN

Cross-sectional study involving in-depth interviews. Participants selected their priorities for emergency care, including aspects they might be prepared to have 'less' of (e.g. rapid access) if it meant having 'more' of another (e.g. consultant-delivered care). A thematic analysis was carried out, combining inductive and deductive approaches, drawing on theories about risk perception.

SETTING

Two urban areas of England; one where changes to emergency services were under consideration ('Greenville'), and one where they were not ('Hilltown').

PARTICIPANTS

28 participants in total. Greenville interviewees included more common emergency service users - parents of young children (n=5) and older people (n=6) - plus patient representatives and individuals campaigning against service closures (n=9). Hilltown interviewees (n=8) received outpatient care for Chronic Obstructive Pulmonary Disease, an important cause of emergency admission.

RESULTS

Most participants, in both areas, were not willing to accommodate the trade-offs involved in consolidating emergency services, principally because of the belief that timely access is associated with better outcomes. Participants did not consider the proposed improvements as gains worth having; interviewees believed care quality would be adversely impact, partly because increased patient numbers would place staff under greater pressure and result in longer waiting times.

CONCLUSIONS

Visible clinical leadership and detailed explanation of the case for change were insufficient to overcome opposition to the reconfiguration in Greenville, challenging the assumption that communities can be persuaded by evidence. Commissioners should make explicit credible plans to accommodate changes in patient flows, as well as clarifying the roles played by key staff groups.

Evaluating the impact of the reconfiguration of gynaecology services at a University Hospital NHS trust in the United Kingdom

BACKGROUND

The project aim was to investigate the impact of reconfiguring gynaecology services on the key performance indicators of a University Hospital NHS Trust in the UK. The reconfiguration involved the centralisation of elective gynaecology on one hospital site and emergency gynaecology on the other.

METHODS

Data measuring outcomes of the Trust's performance indicators (clinical outcomes, patient experience, staff satisfaction, teaching/training, research/development and value for money) were collected. Two time periods, 12 months before and after the reconfiguration in March 2011, were compared for all outcome measures except patient experience. Retrospective data from the hospitals audit department on clinical activity/outcomes and emergency gynaecology patient's feedback questionnaires were analysed. Staff satisfaction, teaching/training and research/development were measured through an online survey of gynaecology consultants.

RESULTS

Post reconfiguration, the total number of admissions reduced by 6% (6,867 vs 6,446). There was a 14% increase in elective theatre sessions available (902.29 vs 1030.57) and an 84% increase in elective theatre sessions cancelled (44.43 vs 81.71). However, the average number of elective operations performed during each theatre session remained similar (2.63 vs 2.5). There was a significant increase in medical devices related clinical incidents (2 vs 11). With patient experience, there was a significant reduction in patient's overall length of stay on the emergency gynaecology ward and waiting times for investigations. For staff satisfaction, Consultants were significantly more dissatisfied with workload (3.45 vs 2.85) and standards of care (3.75 vs 2.93). With research and development, consultants remained dissatisfied with time/funding/opportunities for research. No significant impact on undergraduate/postgraduate teaching was found. No financial data on gynaecology was provided for the assessment of value for money.

CONCLUSIONS

Reconfiguration of gynaecology services at this Trust may have resulted in a reduction in gynaecological activity and increased cancellation of elective operations but did not significantly reduce the number of elective operations performed. Although consultants expressed increased dissatisfaction with standards of clinical care, clinical incident reports did not significantly increase apart from medical devices incidents. Patient experience of emergency gynaecology services was improved. This manuscript provides a framework for similar exercises evaluating the impact of service redesign in the NHS.

Hospital restructuring and physician job satisfaction: an empirical study

The adoption of clinical directorates through the internal reconfiguration of hospital organizations has been one of the most widespread restructuring interventions in many Western European countries. Despite its extensive adoption, a lack of knowledge remains on the analysis of how this reorganization affects professionals' job satisfaction. This paper contributes to the debate on clinical directorates by exploring how the structural characteristics of newly adopted organizational models influence physician's job satisfaction. More than 300 physicians in 18 clinical directorates in the Italian National Health Service were surveyed regarding their overall job satisfaction following the introduction of departmental arrangements. Survey results were then linked to another survey that classified newly adopted models according to the criteria used to merge hospital wards into directorates, by recognizing "Process-integration", "Specialty-integration" and "Mixed-integration" types of directorates. Our findings show that structural aspects of change significantly influenced overall job satisfaction, and that a physician's openness to experience moderated the adoption and implementation of new clinical directorates. Specifically, results demonstrate that physicians with high openness to experience scores were more receptive to the positive impacts of change on overall job satisfaction. Implications for how these findings may facilitate organizational shifts within hospital settings are discussed.

Implementing market-based reforms in the English NHS: bureaucratic coping strategies and social embeddedness

This paper reports findings from an ethnographic study that explored how market-based policies were implemented in one local health economy in England. We identified a number of coping strategies employed by local agents in response to multiple, rapidly changing and often contradictory central policies. These included prioritising the most pressing concern, relabelling existing initiatives as new policy and using new policies as a lever to realise local objectives. These coping strategies diluted the impact of market-based reforms. The impact of market-based policies was also tempered by the persistence of local social relationships in the form of 'sticky' referral patterns and agreements between organisations not to compete. Where national market-based policies disrupted local relationships they produced unintended consequences by creating an adversarial environment that prevented collaboration.

Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation of two models of stroke care

BACKGROUND

Significant changes in provision of clinical care within the English National Health Service (NHS) have been discussed in recent years, with proposals to concentrate specialist services in fewer centres. Stroke is a major public health issue, accounting for over 10% of deaths in England and Wales, and much disability among survivors. Variations have been highlighted in stroke care, with many patients not receiving evidence-based care. To address these concerns, stroke services in London and Greater Manchester were reorganised, although different models were implemented. This study will analyse processes involved in making significant changes to stroke care services over a short time period, and the factors influencing these processes. We will examine whether the changes have delivered improvements in quality of care and patient outcomes; and, in light of this, whether the significant extra financial investment represented good value for money.

METHODS/DESIGN

This study brings together quantitative data on 'what works and at what cost?' with qualitative data on 'understanding implementation and sustainability' to understand major system change in two large conurbations in England. Data on processes of care and their outcomes (e.g. morbidity, mortality, and cost) will be analysed to evidence services' performance before and after reconfiguration. The evaluation draws on theories related to the dissemination and sustainability of innovations and the 'social matrix' underlying processes of innovation. We will conduct a series of case studies based on stakeholder interviews and documentary analysis. These will identify drivers for change, how the reconfigurations were governed, developed, and implemented, and how they influenced service quality.

DISCUSSION

The research faces challenges due to: the different timings of the reconfigurations; the retrospective nature of the evaluation; and the current organisational turbulence in the English NHS. However, these issues reflect the realities of major systems change and its evaluation. The methods applied in the study have been selected to account for and learn from these complexities, and will provide useful lessons for future reconfigurations, both in stroke care and other specialties.