Regional assemblage and the spatial reorganisation of health and care: the case of devolution in Greater Manchester, England

The impact of devolution on local health systems: Evidence from Greater Manchester, England

Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. We evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach. We estimated the impact of devolution until February 2020 on 98 measures of health system performance, using the generalised synthetic control method and adjusting for multiple hypothesis testing. We selected measures from existing monitoring frameworks to populate the WHO Health System Performance Assessment framework. The included measures captured information on health system functions, intermediatory objectives, final goals, and social determinants of health. We identified which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents. Life expectancy (0.233 years, S.E. 0.012) and healthy life expectancy (0.603 years, S.E. 0.391) increased more in GM than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with social determinants of health, including a reduction in alcohol-related admissions (-110.1 admission per 100,000, S.E. 9.07). In contrast, the impact on outpatient, mental health, maternity, and dental services was mixed. Devolution was associated with improved population health, driven by improvements in health services and wider social determinants of health. These changes occurred despite limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-making across health, social care, and wider public services in the region.

'The night is for sleeping': how nurses care for conflicting temporal orders in older person care

This paper examines the conflicting temporal orders of the regional nurse, a role which has been introduced to deal with the increasing demands of aged care and workforce shortages in regional settings. We build on ethnographic research in the Netherlands, in which we examine regional district nurses as a new professional role that attends to (sub)acute care needs, connecting and coordinating different places of care during out of office hours. We use the concept of 'temporal regional order' to reflect on the different ways caring practices are temporally structured by management and care practitioners, in close interaction with patients and informal care givers. In the results three types of disruptions of the regional temporal order are distinguished: interfering bodily rhythms and needs; (un)expected workings of technologies; and disrupting acts of patient and relatives. It was region nurses' prime responsibility to stabilise these interferences and prevent or soften a disruption of the regional order. In accomplishing this, we show how nurses craft their professional role in between various care settings, without getting involved too much in patient care, to be mobile as 'temporal caregivers'.

Developing architecture of system management in the English NHS: evidence from a qualitative study of three Integrated Care Systems

OBJECTIVE

Integrated Care Systems (ICSs) mark a change in the English National Health Service to more collaborative interorganisational working. We explored how effective the ICS form of collaboration is in achieving its goals by investigating how ICSs were developing, how system partners were balancing organisational and system responsibilities, how partners could be held to account and how local priorities were being reconciled with ICS priorities.

DESIGN

We carried out detailed case studies in three ICSs, each consisting of a system and its partners, using interviews, documentary analysis and meeting observations.

SETTING/PARTICIPANTS

We conducted 64 in-depth, semistructured interviews with director-level representatives of ICS partners and observed eight meetings (three in case study 1, three in case study 2 and two in case study 3).

RESULTS

Collaborative working was welcomed by system members. The agreement of local governance arrangements was ongoing and challenging. System members found it difficult to balance system and individual responsibilities, with concerns that system priorities could run counter to organisational interests. Conflicts of interest were seen as inherent, but the benefits of collaborative decision-making were perceived to outweigh risks. There were multiple examples of work being carried out across systems and 'places' to share resources, change resource allocation and improve partnership working. Some interviewees reported reticence addressing difficult issues collaboratively, and that organisations' statutory accountabilities were allowing a 'retreat' from the confrontation of difficult issues facing systems, such as agreeing action to achieve financial sustainability.

CONCLUSIONS

There remain significant challenges regarding agreeing governance, accountability and decision-making arrangements which are particularly important due to the recent Health and Care Act 2022 which gave ICSs allocative functions for the majority of health resources for local populations. An arbiter who is independent of the ICS may be required to resolve disputes, along with increased support for shaping governance arrangements.

"Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration

BACKGROUND

The reconfiguration of specialist hospital services, with service provision concentrated in a reduced number of sites, is one example of major system change (MSC) for which there is evidence of improved patient outcomes. This paper explores the reconfiguration of specialist oesophago-gastric (OG) cancer surgery services in a large urban area of England (Greater Manchester, GM), with a focus on the role of history in this change process and how reconfiguration was achieved after previous failed attempts.

METHODS

This study draws on qualitative research from a mixed-methods evaluation of the reconfiguration of specialist cancer surgery services in GM. Forty-six interviews with relevant stakeholders were carried out, along with ~160 hours of observations at meetings and the acquisition of ~300 pertinent documents. Thematic analysis using deductive and inductive approaches was undertaken, guided by a framework of 'simple rules' for MSC.

RESULTS

Through an awareness of, and attention to, history, leaders developed a change process which took into account previous unsuccessful reconfiguration attempts, enabling them to reduce the impact of potentially challenging issues. Interviewees described attending to issues involving competition between provider sites, change leadership, engagement with stakeholders, and the need for a process of change resilient to challenge.

CONCLUSION

Recognition of, and response to, history, using a range of perspectives, enabled this reconfiguration. Particularly important was the way in which history influenced and informed other aspects of the change process and the influence of stakeholder power. This study provides further learning about MSC and the need for a range of perspectives to enable understanding. It shows how learning from history can be used to enable successful change.

"Attending to Collaboration" in Major System Change in Healthcare in England: A Response Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration"

In this short article we comment upon the recent article by Perry et al "Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration. We welcome the engagement with power, history and heuristics in the Perry et al paper. Our article discusses the importance of researcher positionality in Major System Change research, alongside managerial power and the centrality of politics to remaking health and care services. Additionally, we highlight the work of Ansell and Gash focused on 'collaborative governance' and its potential to offer insight in relation to Major System Change.

Linking Costs and Quality in Healthcare: Towards Sustainable Healthcare Systems Comment on "Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies"

Organisation-wide studies in cost and quality of care are rare, and Wackers et al make a valuable contribution in synthesizing the literature on this issue. Their paper provides a good overview of initiatives and a list of factors that help in furthering organisation-wide change. The eleven factors they distill from the literate however remain rather abstract and more work needs to be done to contextualize the factors and the work that is needed to accomplish them and to see how they are aligned. Challenges in healthcare quality and costs moreover increasingly cross organizational boundaries and we need new methods to study and evaluate these.

Challenges and chances for local health and social care integration – Lessons from Greater Manchester, England

Purpose

Sustainability and transformation partnerships (STPs) were introduced to England, asking 44 local areas to submit their health and social care plans for the period from October 2016 to March 2021. This study aims to offer a deeper understanding of the complex structure in the local practice, and to discuss the associated challenges and chances.

Design/methodology/approach

Documentary analysis, qualitative interviews and questionnaire survey are used for this study. Findings have been compared and analysed thematically.

Findings

The study participants reported that apart from pooled budgets, past collaborative experience and local leadership are crucial elements for transforming health and social care integration in Greater Manchester (GM). Also, this study provides policy recommendations to promote effective collaborative partnerships in local practices and mitigate local inequity of funding progress.

Research limitations/implications

The findings of this paper cannot be extrapolated to all stakeholders due to the limited samples. Meanwhile, some of the discussions about the case of GM may not be transferrable to other STPs.

Originality/value

This study argues that the success of pooled budgets is the result, rather than the cause, of effective negotiations between various stakeholders; and therefore, there is no evidence suggesting that pooled budgets can resolve the discoordination of health and social care. Moreover, due to the bottom-up approach adopted by STPs, more effective boroughs tend to receive additional funding, resulting in an increasing gap of development between effective and ineffective boroughs.

Regionalization in elderly care: what makes up a healthcare region?

Purpose

The purpose of this paper is to explore the formation and composition of “regions” as places of care, both empirically and conceptually.

Design/methodology/approach

This paper draws on action-oriented research involving experiments aimed at designing, implementing and evaluating promising solutions to the entwined problems of a burgeoning elderly population and an increasing shortage of medical staff. It draws on ethnographic research conducted in 14 administrative areas in the Netherlands, a total of 273 in-depth interviews and over 1,000 h of observations.

Findings

This research challenges the understanding of a healthcare region as a clearly bounded topological area. It shows that organizations and professionals collaborate in a variety of different networks, some conterminous with the administrative region established by policymakers and others not. These networks are by nature unstable and dynamic. Attempts to form new regional collaborations with neighbouring organizations are complicated by existing healthcare governance and accountability structures that position organizations as competitors.

Practical implications

Policymakers should take the pre-established partnerships of healthcare organizations into account before delineating the area in which regionalization is meant to take place. A better alignment of governance and accountability structures is also needed for regionalization to occur in healthcare.

Originality/value

This paper combines insights from valuation studies with sociogeographical literature and provides a framework for understanding the assembling and disassembling of “regions”.

Triage as an infrastructure of care: The intimate work of redistributing medical care in nursing homes

This article explores how professionals in older persons care work on a triage system in the daily care setting. We follow how triage is introduced in older persons care organizations in The Netherlands, to deal with a scarcity of physicians and distribute care among health workers in the region. We offer a sociological analysis in which we use the notion of infrastructure and infrastructural work to study how professionals work with triage in the daily care setting. This study is based on a formative evaluation in which we as researchers both studied and contributed to the construction of the triage system by sharing and participating in reflexive infrastructural work practices. We show how this method enabled to gradually adjust the triage system to the daily practices of care delivery, taking the spatial-temporal setting of care into account. We argue that triage not only structures and simplifies but also opens up new ways of re-placing medical and care work, both professionally and geographically. As our results reveal, re-placing physicians has complex effects above and beyond the efficient deployment of medical staff. Triage as infrastructure not only changes the location, but also reconfigures the relationships physicians have with residents and nurse aids.

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.

Boundary organising in healthcare: theoretical perspectives, empirical insights and future prospects

Purpose

The purpose of this paper is to introduce a special issue on boundary organising in healthcare bringing together a selection of six leading papers accepted for presentation at the 12th Organisational Behaviour in Health Care (OBHC 2020) Conference.

Design/methodology/approach

In this introductory paper, the guest editors position the special issue papers in relation to the theoretical literature on boundaries and boundary organising and highlight how these contributions advance our understanding of boundary phenomena in healthcare.

Findings

Three strands of thinking – practice-based, systems theory and place-based approaches – are briefly described, followed by an analytical summary of the six papers included in the special issue. The papers illustrate how the dynamic processes of boundary organising, stemming from the dual nature of boundaries and boundary objects, can be constrained and enabled by the complexity of broader multi-layered boundary landscapes, in which local clinical and managerial practices are embedded.

Originality/value

The authors set the scene for the papers included in the special issue, summarise their contributions and implications, and suggest directions for future research.

Research implications/limitations

The authors call for interdisciplinary and multi-theoretical investigations of boundary phenomena in health organisation and management, with a particular attention to (1) the interplay between multiple types of boundaries, actors and objects operating in complex multi-layered boundary systems; (2) diversity of the backgrounds, experiences and preferences of patients and services users and (3) the role of artificial intelligence and other non-human actors in boundary organising.

Practical implications

Developing strategies of reflection, mitigation, justification and relational work is crucial for the success of boundary organising initiatives.

Post-place care: disrupting place-care ontologies

With the advent of telecare and the logic of information technologies in health care, the idea of placeless care has taken root, capturing imaginations and promising placeless caring futures. This 'de-territorialisation of care' has been challenged by studies of care practices 'on the ground', showing that care is always (materially) placed. Yet, while sociological scholarship has taken the role of place seriously, there is little conceptual attention for how we may think through immateriality and the changing nature of place in health care. Based on a case study of the introduction of a sensory reality technology into a care organisation, this paper argues that we need (1) to push the definition of placed care into new (digitally produced) landscapes and (2) a new vocabulary, with which to address and conceptualise this changing nature of care places. The paper introduces the term post-place, as a first step in developing such a vocabulary. Post-place care, unlike the idea of placeless care or emplaced care, is an inclusive, open and generative concept. Its strength lies in its disruptive potential for challenging existing place-care ontologies and opening up productive space for thinking through the changing landscapes of health care.

Deprivation and primary care funding in Greater Manchester after devolution: a cross-sectional analysis

BACKGROUND

In April 2016 Greater Manchester gained control of its health and social care budget, a devolution that aimed to reduce health inequities both within Greater Manchester and between Greater Manchester and the rest of the country.

AIM

To describe the relationship between practice location deprivation and primary care funding and care quality measurements in the first year of Greater Manchester devolution (2016/2017).

DESIGN AND SETTING

Cross-sectional analysis of 472 general practices in Greater Manchester in England.

METHOD

Financial data for each general practice were linked to the area deprivation of the practice location, as measured by the 2015 Index of Multiple Deprivation. Practices were categorised into five quintiles relative to national deprivation. NHS Payments data and indicators of care quality were compared across social deprivation quintiles.

RESULTS

Practices in areas of greater deprivation did not receive additional funding per registered patient. Practices in less deprived quintiles received higher National Enhanced Services payments from NHS England than practices in the most deprived quintile. A trend was observed towards funding to more deprived practices being supported by Local Enhanced Service payments from clinical commissioning groups, but these represent a small proportion of overall practice income. Practices in less deprived areas had better care quality measurements according to Quality and Outcomes Framework achievement and Care Quality Commission ratings.

CONCLUSION

Following devolution, primary care practices in Greater Manchester are still reliant on funding from national funding schemes, which poorly reflect its deprivation. The devolved administration's ability to address health inequities at the primary care level seems uncertain.