The policy work of piloting: Mobilising and managing conflict and ambiguity in the English NHS

Crop Straw Resource Utilization as Pilot Policy in China: An Event History Analysis

Massively generated crop straw can be utilized and valorized with great economic and environmental benefits. The Chinese government has adopted the pilot policy of crop straw resource utilization (CSRU) for disposing of the straw and practicing waste valorization. This work took 164 counties in the Hebei Province of China as a case study, mapped the temporal and spatial characteristics of the diffusion of the CSRU pilot policy in this province, and conducted an Event History Analysis by establishing a binary logistic regression model to identify the specific factors that determine the diffusion of the CSRU pilot policy in China from the aspects of resource availability, internal capacity, and external pressure. It indicates that: (1) the CSRU pilot policy diffuses rapidly in Hebei Province, although it is still at the early stage of this policy diffusion; (2) the model explains 95.2% of the variance in adopting a pilot county, indicating the effectiveness of this model; (3) straw resource density has a positive impact on CSRU pilot selections, and it can increase the possibility of one county being selected as a CSRU pilot by 23.2%, while population density has shown a negative effect; (3) policy support from local government is a major internal factor that determines CSRU performance, and it can increase the possibility of one county being selected as a CSRU pilot nearly tenfold; proximity pressure from neighboring counties has a positive effect on the diffusion of the CSRU policy, and it also greatly increases the possibility of being selected as a CSRU pilot.

General practice managers' motivations for skill mix change in primary care: Results from a cross-sectional survey in England

OBJECTIVES

The objectives are to determine the factors that motivated GP practice managers in England to employ non-medical roles, and to identify an ideal hypothetical GP practice workforce.

METHODS

Cross-sectional survey of GP practice managers in England (n = 1205). The survey focused on six non-medical roles: advanced nurse practitioner, specialist nurse, health care assistant, physician associate, paramedic and pharmacist.

RESULTS

The three most commonly selected motivating factors were: (i) to achieve a better match between what patients need and what the practitioner team can deliver; (ii) to increase overall appointment availability and (iii) to release GP time. Employment of pharmacists and physician associates was most commonly supported by additional funding. Practice managers preferred accessing new non-medical roles through a primary care network or similar, while there was a clear preference for direct employment of additional GPs, advanced nurse practitioners or practice nurses. The ideal practice workforce would comprise over 70% of GPs and nurses, containing, on average, fewer GPs than the current GP practice workforce.

CONCLUSION

This study confirms that more diverse teams of practitioners are playing an increasing role in providing primary care in England. Managers prefer not to employ all new roles directly within the practice. A more detailed investigation of future workforce requirements is necessary to ensure that health policy supports the funding (whether practice or population based), recruitment, training, deployment and workloads associated with the mix of roles needed in an effective primary care workforce.

Assembling the Healthopolis: Competitive city-regionalism and policy boosterism pushing Greater Manchester further, faster

Health and care policy is increasingly promoted within visions of the competitive city-region. This paper examines the importance of policy boosterism within the political construction of city-regions in the context of English devolution. Based on a two-year case study of health and social care devolution in Greater Manchester, England, we trace the relational and territorial geographies of policy across and through new "devolved" city-regional arrangements. Contributing to geographical debates on policy assemblages and city-regionalism, we advance a conceptual framework linking crisis and opportunity, emulation and exceptionalism, and evidence and experimentation. The paper makes two key contributions. First, we argue health and care policy is increasingly drawn towards the logic of global competitiveness without being wholly defined by neoliberal political agendas. Fostering transnational policy networks helped embed global "best practice" policies while simultaneously hailing Greater Manchester as a place beyond compare. Second, we caution against positioning the city-region solely at the receiving end of devolutionary austerity. Rather, we illustrate how the urgency of devolution was conditioned by crisis, yet concomitantly framed as a unique opportunity by the local state harnessing policy to negotiate a more fluid politics of scale. In doing so, the paper demonstrates how attempts to resolve the "local problem" of governing health and care under austerity were rearticulated as a "global opportunity" to forge new connections between place, health, and economy. Consequently, we foreground the multiple tensions and contradictions accumulating through turning to health and care to push Greater Manchester further, faster. The paper concludes by asking what the present crisis might mean for city-regions in good health and turbulent times.

Policy Rogue or Policy Entrepreneur? The Forms and Impacts of "Joined-Up Governance" for Child Health

Joined-up governance (JUG) approaches have gained attention as mechanisms for tackling wicked policy problems, particularly in intersectoral areas such as child health, where multiple ministries that deliver health and social services must collaborate if they are to be effective. Growing attention to the need to invest in early childhood to improve health and developmental trajectories, including through developmental screening, illustrate the challenges of JUG for child health. Using a comparative case study design comprised of the qualitative analysis of documents and key informant interviews, this work sought to explain how and why visible differences in policy choices have been made across two Canadian jurisdictions (Ontario and Manitoba). Specifically, we sought to understand two dimensions of governance (structure and process) alongside an illustrative example-the case of developmental screening, including how insiders viewed the impacts of governance arrangements in this instance. The two jurisdictions shared a commitment to evidence-based policy making and a similar vision of JUG for child health. Despite this, we found divergence in both governance arrangements and outcomes for developmental screening. In Manitoba, collaboration was prioritized, interests were aligned in a structured decision-making process, evidence and evaluation capacity were inherent to agenda setting, and implementation was considered up front. In Ontario, interests were not aligned and instead decision making operated in an opaque and siloed manner, with little consideration of implementation issues. In these contexts, Ontario pursued developmental screening, whereas Manitoba did not. While both jurisdictions aimed at JUG, only Manitoba developed a coordinated JUG system, whereas Ontario operated as a non-system. As a result, Manitoba's governance system had the capacity to stop 'rogue' action, prioritizing investments in accordance with authorized evidence. In contrast, in the absence of a formal system in Ontario, policy 'entrepreneurs' were able to seize a window of opportunity to invest in child health.

Exploring the multiple policy objectives for primary care networks: a qualitative interview study with national policy stakeholders

OBJECTIVES

English general practice is suffering a workforce crisis, with general practitioners retiring early and trainees reluctant to enter the profession. To address this, additional funding has been offered, but only through participation in collaborations known as primary care networks (PCNs). This study explored national policy objectives underpinning PCNs and the mechanisms expected to help achieve these, from the perspective of those driving the policy.

DESIGN

Qualitative semistructured interviews and policy document analysis.

SETTING AND PARTICIPANTS

National-level policy maker and stakeholder interviewees (n=16). Policy document analysis of the Network Contract Direct Enhanced Service draft service specifications.

ANALYSIS

Interviews were transcribed, coded and organised thematically according to policy objectives and mechanisms. Thematic data were organised into a matrix so prominent elements can be identified and emphasised accordingly. Themes were considered alongside objectives embedded in PCN draft service delivery requirements.

RESULTS

Three themes of policy objectives and associated mechanisms were identified: (1) supporting general practice, (2) place-based interorganisational collaboration and (3) primary care 'voice'. Interviewees emphasised and sequenced themes differently, suggesting meeting objectives for one was necessary to realise another. Interviewees most closely linked to primary care emphasised the importance of theme 1. The objectives embedded in draft service delivery requirements primarily emphasised theme 2.

CONCLUSIONS

These policy objectives are not mutually exclusive but may imply different approaches to prioritising investment or necessitate more explicit temporal sequencing, with the stabilisation of a struggling primary care sector probably needing to occur before meaningful engagement with other community service providers can be achieved or a 'collective voice' is agreed. Multiple objectives create space for stakeholders to feel dissatisfied when implementation details do not match expectations, as the negative reaction to draft service delivery requirements illustrates. Our study offers policy makers suggestions about how confidence in the policy might be restored by crafting delivery requirements so all groups see opportunities to meet favoured objectives.

Participatory implementation research in the field of migrant health: Sustainable changes and ripple effects over time

Objective

This study aimed to explore whether positive impacts were sustained and unanticipated ripple effects had occurred four years after the implementation of interventions to improve cross‐cultural communication in primary care.

Background

Sustaining the implementation of change using complex interventions is challenging. The EU‐funded “RESTORE” study implemented guidelines and training on cross‐cultural communication in five Primary Care sites in Europe, combining implementation theory (Normalisation Process Theory) with participatory methodology (participatory learning and action—PLA). There were positive impacts on knowledge, skills and clinical routines.

Design, setting and participants

Four of the five original sites (England, Ireland, Greece, The Netherlands) were available for this qualitative follow‐up study. The study population (N = 44) was primary healthcare staff and migrants, most of whom had participated in RESTORE.

Intervention; main outcome measures

PLA‐style focus groups and interviews explored routine practice during consultations with migrants. Etic cards based on the effects of RESTORE stimulated the discussion. Deductive framework analysis was performed in each country followed by comparative data analysis and synthesis.

Results

Changes in knowledge, attitudes and behaviour with regard to consultations with migrants were sustained and migrants felt empowered by their participation in RESTORE. There were ongoing concerns about macro level factors, like the political climate and financial policies, negatively affecting migrant healthcare.

Conclusion

There were sustained effects in clinical settings, and additional unanticipated positive ripple effects, due in part, from the participatory approach employed.

From Amsterdam to Bamako: a qualitative case study on diffusion entrepreneurs’ contribution to performance-based financing propagation in Mali

For the past 15 years, several donors have promoted performance-based financing (PBF) in Africa for improving health services provision. European and African experts known as ‘diffusion entrepreneurs’ (DEs) assist with PBF pilot testing. In Mali, after participating in a first pilot PBF in 2012–13, the Ministry of Health and Public Hygiene included PBF in its national strategic plan. It piloted this strategy again in 2016–17. We investigated the interactions between foreign experts and domestic actors towards PBF diffusion in Mali from 2009 to 2018. Drawing on the framework on DEs (Gautier et al., 2018), we examine the characteristics of DEs acting at the global, continental and (sub)national levels; and their contribution to policy framing, emulation, experimentation and learning, across locations of PBF implementation. Using an interpretive approach, this longitudinal qualitative case study analyses data from observations (N = 5), interviews (N = 33) and policy documentation (N = 19). DEs framed PBF as the logical continuation of decentralization, contracting policies and existing policies. Policy emulation started with foreign DEs inspiring domestic actors’ interest, and succeeded thanks to longstanding relationships and work together. Learning was initiated by European DEs through training sessions and study tours outside Mali, and by African DEs transferring their passion and tacit knowledge to PBF implementers. However, the short-time frame and numerous implementation gaps of the PBF pilot project led to incomplete policy learning. Despite the many pitfalls of the region-wide pilot project, policy actors in Mali decided to pursue this policy in Mali. Future research should further investigate the making of successful African DEs by foreign DEs advocating for a given policy.