Healthcare leadership with political astuteness (HeLPA): a qualitative study of how service leaders understand and mediate the informal 'power and politics' of major health system change

A Gateway Framework to Guide Major Health System Changes Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration"

Recent events - on both a global scale and within individual countries - including the lockdowns associated with COVID-19 pandemic, inflation concerns, and political tensions, have increased pressure to reconfigure social services for ongoing sustainability. Healthcare services across the world are undergoing major system change (MSC). Given the complexity and different contextual drivers across healthcare systems, there is a need to use a variety of perspectives to improve our understanding of the processes for MSC. To expand the knowledge base and develop strategies for MSC requires analysing change projects from different perspectives to distil the elements that drove the success. We offer the Gateway Framework as a collaborative transformational system tool to assess and reorganise operations, services, and systems of healthcare organisations. This framework and guiding questions, accounts for past events whilst being proactive, future orientated, and derived from externally defined and a standardised requirements to promote safe, high-quality care.

What makes a socially skilled leader? Findings from the implementation and operation of New Care Models (Vanguards) in England

PURPOSE

The article aims to argue that the concept of "distributed leadership" lacks the specificity required to allow a full understanding of how change happens. The authors therefore utilise the "Strategic Action Field Framework" (SAF) (Moulton and Sandfort, 2017) as a more sensitive framework for understanding leadership in complex systems. The authors use the New Care Models (Vanguard) Programme as an exemplar.

DESIGN/METHODOLOGY/APPROACH

Using the SAF framework, the authors explored factors affecting whether and how local Vanguard initiatives were implemented in response to national policy, using a qualitative case study approach. The authors apply this to data from the focus groups and interviews with a variety of respondents in six case study sites, covering different Vanguard types between October 2018 and July 2019.

FINDINGS

While literature already acknowledges that leadership is not simply about individual leaders, but about leading together, this paper emphasises that a further interdependence exists between leaders and their organisational/system context. This requires actors to use their skills and knowledge within the fixed and changing attributes of their local context, to perform the roles (boundary spanning, interpretation and mobilisation) necessary to allow the practical implementation of complex change across a healthcare setting.

ORIGINALITY/VALUE

The SAF framework was a useful framework within which to interrogate the data, but the authors found that the category of "social skills" required further elucidation. By recognising the importance of an intersection between position, personal characteristics/behaviours, fixed personal attributes and local context, the work is novel.

Is the end in sight? A study of how and why services are decommissioned in the English National Health Service

The decommissioning of a health-care service is invariably a highly complex and contentious process which faces many implementation challenges. There has been little specific theorisation of this phenomena, although insights can be transferred from wider literatures on policy implementation and change processes. In this paper, we present findings from empirical case studies of three decommissioning processes initiated in the English National Health Service. We apply Levine's (1979, Public Administration Review, 39(2), 179-183) typology of decommissioning drivers and insights from the empirical literature on pluralistic health-care contexts, complex change processes and institutional constraints. Data include interviews, non-participant observation and documents analysis. Alongside familiar patterns of pluralism and political partisanship, our results suggest the important role played by institutional factors in determining the outcome of decommissioning processes and in particular the prior requirement of political vulnerability for services to be successfully closed. Factors linked to the extent of such vulnerability include the scale of the proposed changes and extent to which they are supported at the macrolevel.

Managing Complex Healthcare Change: A Qualitative Exploration of Current Practice in New South Wales, Australia

PURPOSE

As the cost of healthcare continues to rise, healthcare organizations internationally are seeking long-term solutions to eradicate inefficiency, achieve value-based healthcare, and minimize hospital inpatient services. This requires transformational change in healthcare organizations, and associated change management and leadership capability at multiple levels. Despite the critical need for effective change leadership and management in healthcare, limited evidence exists that this currently occurs in addition to the capability and capacity for managing change in health systems.

METHODS

Semi-structured interviews were undertaken with 16 healthcare managers and leaders at a range of levels in nine healthcare organizations across the public health system of one Australian state (New South Wales), including metropolitan, regional and rural geographical areas. Thematic content analysis was undertaken with the emergent data.

RESULTS

Four key themes emerged from the data: 1) lack of adoption of frameworks and methods for change management for any scope or scale of change, 2) inadequate resources for delivering, managing and leading change, 3) insufficient leadership, capacity and capability in managing change, and 4) the need for support and culture that supports change at all levels of the system.

CONCLUSION

Ensuring dedicated resources for change and sufficient capacity and capability amongst health professionals and managers at every level in a health system are required for effective management of change. An enabling culture for change, supported by adequate education and training in change leadership and management are critical in order for the benefits of health service and system changes to be realised.

Introducing legislative advocacy into the dental school curriculum: A mixed-methods evaluation

The aim of this project was to evaluate a legislative advocacy exercise in pediatric dentistry at 1 North American dental school. A mixed-methods approach was employed using focus groups and questionnaires. All third-year dental students (n = 84) participated in an exercise as part of the pediatric dentistry course. Participation in the program evaluation was voluntary. Questionnaires were administered to assess students' advocacy beliefs, behaviors, self-efficacy, and knowledge 1 week before and 1 week after the exercise. Six months later, a focus group with questionnaire non-respondents (n = 9) was conducted to explore participants' attitudes and beliefs about oral health advocacy within the dental school curriculum. The focus group followed a semi-structured guide, and transcripts were analyzed using thematic content analysis. Questionnaires were returned from 27 students before (33% response rate) and 23 students (28% response rate) following the advocacy exercise. Students' advocacy beliefs, behaviors, and knowledge showed no change, whereas self-efficacy improved following the advocacy exercise. Students enjoyed the advocacy exercise and viewed it as a positive addition to the curriculum; however, they requested more exposure to advocacy across the curriculum. Students described the power of their collective voice rather than a single person as a major driver of policy change. These findings suggest that curricular changes should incorporate experiential advocacy activities more frequently to help students learn about and gain advocacy skills.