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Nasir Hamid
The view from nowhere? How think tanks work to shape health policy
Think tanks seek to shape the business of government by offering policy expertise in a number of areas, including health care. This expertise tends to be presented as ‘the view from nowhere’ – independent, value-neutral expertise that can inform policy. We challenge this view by examining what ‘independence’ means and how it is performed. We present an interpretive policy analysis of data collected from four UK-based think tanks that have sought to influence health policy. Our analysis demonstrates how a sample of healthcare think tanks publicly positioned themselves as ‘independent’ organizations. They drew on technocratic health planning discourse to emphasize a range of knowledge-related activities, artifacts and instrumental language that, informants suggested, allowed them to feed emerging evidence into policy and improve health services. Such positioning seemed to provide them with legitimacy in the eyes of decision makers. A parallel set of think tank activities (e.g., meetings with parliamentarians) took place ‘back-stage’ and focused on influencing health policy and, in the context of recent proposals to reform the English National Health Service, lending broad though not unqualified support to government proposals to extend market principles in health care. Informants appeared to seek to neutralize their presentation of such ‘back-stage’ influencing through a range of discursive strategies.
Thinking about think tanks in health care: A call for a new research agenda
Little sociological attention has been given to the role of think tanks in health policy and planning. Existing work in political science and public administration tends to define and categorise think tanks and situate them as a disinterested source of policy expertise. Despite the increasingly visible presence of think tanks in the world of health care, such work has done little to reveal how they operate, by whom and to what ends. Our article seeks to redress this firstly by examining why they have remained relatively hidden in academic analyses and secondly by advocating an interpretive approach that incorporates think tanks within the wider landscape of health policy and planning. In contrast to most existing literature, an interpretive approach acknowledges that much of the messy business of healthcare policy and planning remains hidden from view and that much can be gleaned by examining the range of organisations, actors, coalitions, everyday activities, artefacts and interactions that make up the think tank stage and that work together to shape health policy and planning. Given the paucity of research in this area, we urge the medical sociology community to open the field to further academic scrutiny. © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd.
The work of commissioning: A multisite case study of healthcare commissioning in England's NHS
Objective: To examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change. Design: Multisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings. Participants: Primary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives. Setting: Three 'commissioning communities' (areas covered by a primary care trust) in England, 2010-2012. Results: Commissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official 'commissioning cycle' promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems. Conclusions: Commissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.
Fragmentation: A wicked problem with an integrated solution?
Integrated care is central to current health care reforms as policy makers and practitioners struggle to address fragmentation of care planning and delivery. However, those pursuing integration have failed to appreciate the complex nature of fragmentation. We seek to bring some much-needed clarity to current debate by considering fragmentation as a 'wicked problem' requiring a locally driven and multifaceted approach to integration. © SAGE Publications Ltd 2013.
Commissioning healthcare for people with long term conditions: The persistence of relational contracting in England's NHS quasi-market
Background: Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market. Methods. We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents. Results: In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services. In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach. Conclusions: Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions. © 2013 Porter et al; licensee BioMed Central Ltd.
Extending primary care: potential learning from Italy.
Health systems across Europe are under increasing pressure to shift care outside hospitals and into community settings. The emphasis is on providing high-quality, coordinated care for a growing population of older patients and those with long-term conditions. Extended primary care is regarded as the key means of achieving such a shift. We report learning following exploratory visits to two sites in Italy, each providing an example of a primary care organisation with extended general practices, community health and local resource utilisation responsibilities. We draw out three areas of potential interest--shifting care from hospital to community settings, facilitating localism and enabling stable leadership--all of which appear to provide a means for local clinicians, managers and their communities to commission care according to local needs. We conclude by recommending that primary care researchers consider undertaking further work in Italy, building on this exploratory work and more systematically exploring the effects of such programmes.
Horizontal and vertical integration in the UK: Lessons from history
Policy makers, practitioners and researchers have increasingly emphasised the need for both vertical and horizontal 'integration' and 'integrated care'. This is not new; since the inception of the NHS wide-ranging policies and programmes have sought to co-ordinate services better. Current UK policy, however, tends to overlook this historical record and, in so doing, ignores potential learning from the past. We seek to help rectify this approach by reviewing historical (published and grey) literature over the past one hundred years, considering both the drivers for and the impediments to varied UK policy developments in integrating health and allied services. We aim to shed light on how the policy of integrated care has developed in the UK and draw out lessons for modern-day policy makers. © Pier Professional Ltd.
Reaching the parts that other theories and methods can't reach: How and why a policy-as-discourse approach can inform health-related policy
This article illustrates how conceptualizing policy-as-discourse offers opportunities for those with a vested interest in policy to 'reach the parts that other theories and methods can't reach'. First, it explores the dialogical relationship between theory and method in the context of policy analysis, summarizing contemporary writing on conceptualizing and analysing policy and drawing on the work of Bacchi to describe the theoretical underpinnings of three different policy representations along with methodological corollaries, research practices and disclosures about the world that flow from each. This involves reflecting on three different answers to the question 'what is policy?': considering how policy might be conceptualized and analysed under each and narrating the kind of research stories that emerge. Second, the article focuses on one of Bacchi's representations - policy-as-discourse - to provide readers with a case study of this dialogical relationship and drawing on published research exploring the development of primary care research policy to illustrate what elements of discursive policy analysis might look like. Last, the article concludes by reflecting on the ways in which such an approach may (and may not) prove valuable in analysing health-related policy. © The Author(s) 2010.
Shaping the future of integrated care: what can we learn from history
Introduction Published literature on integrated care usefully brings together wide-ranging definitions and concepts (e.g., breadth, function) but pays little attention to the historical record (e.g., political priorities, policy agendas, and social pressures). Historical analysis highlights how these factors have shaped the integrated care agenda over time. Aim To draw out lessons for future policy by considering UK policy developments around ‘integration’ since 1948. Methods Literature-based review, combining historical evidence (1910 onwards) from UK published and grey literature. Analysis of integration of health and social care, and the integration of primary and secondary care. Results and conclusions Historical analysis reveals that policymakers have often shared a desire to improve the quality and efficiency of services by coordinating policies, processes, organisations, services and actors. Key ‘drivers’ of integration have been changing professional and public perceptions of the remit of the health services, which organisations have a part to play in safeguarding the public’s health, and how we conceptualise the boundaries of healthcare. However, history also teaches us how easily reforms currently envisaged as furthering the cause of integration can, in the long run, further cement existing gaps in service provision.
Discourse analysis: What is it and why is it relevant to family practice?
This paper aims to illustrate what discourse analysis is and how it can contribute to our understanding of family practice. Firstly, we describe what 'discourse analysis' is, mapping the discourse analysis terrain by discussing four studies relevant to primary care to illustrate different methodological approaches and key concepts. We then address the practicalities of how to actually do discourse analysis, providing readers with a worked example using one particular approach. Thirdly, we touch on some common debates about discursive research. We conclude by advocating that researchers and practitioners take up the challenge of understanding, utilizing and extending the field of discourse studies within family practice. © 2009 The Authors.
A double-edged sword? Health research and research governance in UK primary care
Contemporary health research is becoming increasingly formalised, regulated and institutionalised. In the UK, this has manifested itself in the development of a framework for 'governing' health research. The framework is often presented as a neutral decision-making tool guiding elements of research (such as ethical and peer review) through formal governance processes and approval procedures. We locate the framework as emerging in the wider context of the growth of 'guidelines' in healthcare that raises questions about the extent to which formal rationality has taken hold on knowledge production and what this means for health research. We therefore explore if and how the framework prioritises particular approaches to the production of knowledge and the tensions that emerge between managerial requirements and the work of researchers. We employed qualitative telephone interviews to access the accounts of both researchers and administrators across a range of primary healthcare settings in England and to capture a range of experiences and levels of involvement in research and governance. Our analysis revealed the double-edged nature of research governance: on the one hand, the framework provided a valuable aid to decision-making and the formalisation of tacit knowledge about 'good research practice'; on the other, consequent managerial processes engaged researchers in a series of low-level activities and privileged particular ways of viewing the world. Our findings add to existing knowledge by moving beyond documenting concerns over research governance and show how the reduction of research governance according to a 'common' set of principles and procedures facilitates the production (and managerial oversight) of quantitative and clinical, over qualitative and experiential, knowledge. © 2008 Elsevier Ltd. All rights reserved.
What are the ‘success factors’ for effective integration? Lessons from international case studies
Purpose To describe key success factors, derived from literature review and international case studies that enable effective integration between clinicians, teams and organizations. Theory Effective integration is dependent on consideration of diverse factors operating at macro, meso and micro levels of health care. Data sources Literature review and four international case studies. Methods A maximum variation sample of four ICOs was selected from organizations and services nominated by international experts as ‘high performing’; ensuring a range of national policy contexts, organizational arrangements, and integrative approaches. Case studies in the USA, Holland and Scotland, drew on data from 10 to 15 semi-structured interviews with managers and clinicians and on document review. Interviews explored understanding of and objectives for ‘integration’, external influences and impact of internal characteristics (e.g. leadership, governance, IT) in facilitating/hindering integration. Clinical interviewees also described hypothetical patient journeys. Analysis focused on potential barriers and facilitators to integration. Preliminary conclusions Findings suggest integration requires four tiers of ‘success factors’: 1) a supportive ‘operating environment’ with appropriate policy, regulation, law, and payment systems; 2) organisational culture, infrastructure and processes (which may cross organizational boundaries) to support integration and enable; 3) effective inter-professional teams operating within or between organizations with linked infrastructure; shared assessments; common standards; care co-ordination and shared care plans and 4) activated patients to participate in care planning. Discussion Those wishing to develop effective ICOs will need to ensure that each of these four tiers is addressed simultaneously across all levels (i.e. macro, meso and micro) of health care.