Background: The relationship between healthcare interventions and context is widely conceived as involving complex and dynamic interactions over time. However, evaluations of complex health interventions frequently fail to mobilise such complexity, reporting context and interventions as reified and demarcated categories. This raises questions about practices shaping knowledge about context, with implications for who and what we make visible in our research. Viewed through the lens of case study research, we draw on data collected for the Triple C study (focused on Case study, Context and Complex interventions), to critique these practices, and call for system-wide changes in how notions of context are operationalised in evaluations of complex health interventions. Methods: The Triple C study was funded by the Medical Research Council to develop case study guidance and reporting principles taking account of context and complexity. As part of this study, a one-day workshop with 58 participants and nine interviews were conducted with those involved in researching, evaluating, publishing, funding and developing policy and practice from case study research. Discussions focused on how to conceptualise and operationalise context within case study evaluations of complex health interventions. Analysis focused on different constructions and connections of context in relation to complex interventions and the wider social forces structuring participant\u2019s accounts. Results: We found knowledge-making practices about context shaped by epistemic and political forces, manifesting as: tensions between articulating complexity and clarity of description; ontological (in)coherence between conceptualisations of context and methods used; and reified versions of context being privileged when communicating with funders, journals, policymakers and publics. Conclusion: We argue that evaluations of complex health interventions urgently requires wide-scale critical reflection on how context is mobilised - by funders, health services researchers, journal editors and policymakers. Connecting with how scholars approach complexity and context across disciplines provides opportunities for creatively expanding the field in which health evaluations are conducted, enabling a critical standpoint to long-established traditions and opening up possibilities for innovating the design of evaluations of complex health interventions.
\n \n\n \n \nObjectives When seeking to prevent type 2 diabetes, a balance must be struck between individual approaches (focusing on people's behaviour choices') and population approaches (focusing on the environment in which those choices are made) to address the socioeconomic complexity of diabetes development. We sought to explore how this balance is negotiated in the accounts of policy-makers developing and enacting diabetes prevention policy. Methods Twelve semistructured interviews were undertaken with nine UK policy-makers between 2018-2021. We explored their perspectives on disease prevention strategies and what influenced policy decision-making. Interviews were transcribed and analysed thematically using NVIVO. We used Shiffman's political priority framework to theorise why some diabetes prevention policy approaches gather political support while others do not. Results The distribution of power and funding among relevant actors, and the way they exerted their power determined the dominant approach in diabetes prevention policy. As a result of this distribution, policy-makers framed their accounts of diabetes prevention policies in terms of individual behaviour change, monitoring personal quantitative markers but with limited ability to effect population-level approaches. Such an approach aligns with the current prevailing neoliberal political context, which focuses on individual lifestyle choices to prevent disease rather than on infrastructure measures to improve the environments and contexts within which those choices are made. Conclusion Within new local and national policy structures, there is an opportunity for collaborative working among the National Health Service, local governments and public health teams to balance the focus on disease prevention, addressing upstream drivers of ill health as well as targeting individuals with the highest risk of diabetes.
\n \n\n \n \nVirtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This \u201cperspective\u201d paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations\u2019 access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the \u201csolution to everything\u201d. In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial \u201cDirect-To-Consumer\u201d services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to \u201ccapabilities\u201d supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing \u201cpublic health value\u201d through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.
\n \n\n \n \nBackground Group consultations have been gaining ground as a novel approach to service delivery. When in-person care was restricted owing to COVID-19, general practice staff began delivering group consultations remotely over video. Aim To examine how multiple interacting influences underpinned implementation and delivery of video group consultations (VGCs). Design and setting Qualitative study in general practice in England. Method a) 32 semi-structured interviews with patients, clinical, and non-clinical staff (from eight GP surgeries in total), NHS policymakers and programme managers, and other stakeholders; b) observation in relevant training and operational meetings; and c) three co-design workshops (21 participants). Thematic analysis was informed by the Planning and Evaluating Remote Consulting Services (PERCS) framework. Results In the first year of the pandemic, VGCs focused on supporting those with long-term conditions or other shared health and social needs. Most patients welcomed clinical and peer input, and the opportunity to access their practice remotely during lockdown. However, not everyone agreed to engage in group-based care or was able to access IT equipment. At practice level, significant work was needed to deliver VGCs, such as setting up the digital infrastructure, gaining team buy-in, developing new patient-facing online facilitation roles, managing background operational processes, protecting online confidentiality, and ensuring professional indemnity cover. Training provided nationally was seen as instrumental in capacity building for VGC implementation. Conclusion Small scale VGC implementation addressed unmet need during the pandemic. However, embedding VGCs in routine care requires rethinking of operational, infrastructural, and clinical processes. Additional research on costs and benefits at service and patient level is needed.
\n \n\n \n \nBackground: There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research. Methods: Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing \u2018hybrid papers\u2019 (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions. Results: We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently\u2014respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of \u2018the case\u2019 and \u2018context\u2019 or considered the implications of such conceptualisations for methods and knowledge production. Conclusions: Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.
\n \n\n \n \nTechnology development is gathering pace in epilepsy with seizure detection devices promising to transform self-care and service provision. However, such accounts often neglect the uncertainties, displacements and responsibilities that technology-supported care generates. This review brings together a heterogeneous literature, identified through systematic searches in 8 databases and snowball searching, to interrogate how technology becomes positioned in epilepsy care. We took a hermeneutic approach in our analysis of the 206 included articles, which resulted in the development of a conceptual framework surfacing the underlying logics by which technology-supported epilepsy care is organised. Each of these logics enacts different techno-scientific futures and carries specific assumptions about how (often imagined) \u2018users\u2019 and their bodies become co-constituted. Our review shows that studies in this area remain primarily deterministic and technology-focused. Few draw phenomenological insights on lived experiences with epilepsy or use social theory to problematise the role of technology. We propose future directions for sociotechnical, theory-driven studies of technology in epilepsy care and offer a framework transferable across other long-term conditions.
\n \n\n \n \nThere is increasing focus on complexity-informed approaches across health disciplines. This attention takes several forms, but commonly involves framing research topics as \u201ccomplex\u201d to justify use of particular methods (e.g., qualitative). Little emphasis is placed on how divergent and convergent ways of knowing complexity become negotiated within academic communities. Drawing on findings from a focused ethnography of an international workshop, we illustrate how health researchers employ \u201cboundary-ordering devices\u201d to navigate different meanings ascribed to complexity while they attempt to sustain interdisciplinary communication and collaboration. These include (a) surfacing (but not resolving) tensions between philosophical grounding of knowledge claims and need for practical purchase, (b) employing techniques of representation and abstraction, and (c) drawing on the fluid, ongoing accomplishment of complexity for different audiences and purposes. Our findings have implications for progressing complexity-informed health research, particularly with respect to qualitative approaches.
\n \n\n \n \nBackground: The need for better methods for evaluation in health research has been widely recognised. The \u2018complexity turn\u2019 has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research\u2014currently denigrated as poor evidence\u2014is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear. Main body: Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports. Conclusion: Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.
\n \n\n \n \nQualitative social scientists working in medical faculties have to meet multiple expectations. On the one hand, they are expected to comply with the philosophical and theoretical expectations of the social sciences. On the other hand, they may also be expected to produce publications which align with biomedical definitions and framings of quality. As interdisciplinary scholars, they must handle (at least) two sets of journal editors, peer reviewers, grant-awarding panels, and conference audiences. In this paper, we extend the current knowledge base on the \u2018dual expectations\u2019 challenge by drawing on Orlikowski and Yates\u2019 theoretical concept of communicative genres. A \u2018genre\u2019 in this context is a format of communication (e.g. letter, email, academic paper, and conference presentation) aimed at a particular audience, having a particular material form and socio-linguistic style, and governed by both formal requirements and unwritten social rules. Becoming a member of any community of practice involves becoming familiar with its accepted communicative genres and adept in using them. Academic writing, for example, is a craft that is learned through participation in the social process of communicating one\u2019s ideas to one\u2019s peers in journal articles and other formats. In this reflective paper, we show how the concept of a communicative genre can sensitise us to the conflicting and often dissonant expectations and rule systems governing different academic fields. We use this key concept to suggest ways in which the faculty can support early-career researchers to progress in careers which straddle qualitative social science and medical science.
\n \n\n \n \nThe abrupt shift from face-to-face general practitioner (GP) consultations to remote ones was one of the most radical changes to the UK National Health Service (NHS) since it was set up in 1948. Overnight, people were blocked from turning up at their GP\u2019s surgery and instead offered telephone, video or email contacts. This chapter considers how the lay press interpreted and conveyed this shift. We systematically collected UK newspaper stories about remote general practice from early 2020, mid 2020 and late 2021, and analysed these for their narrative content and form. The three time periods represented three distinct \u2018eras\u2019. Early in the pandemic, newspapers depicted remote consultations positively as an essential component of the country\u2019s war against the virus (\u2018technology as superhero\u2019). By summer 2020, the incidence of COVID-19 had fallen to a low level, lockdown had ended and many aspects of life were returning to normal. But the Secretary of State for Health (a technology enthusiast) had declared that virtual consultations should continue in order to make the NHS more efficient and modern. The mainstream media made much of this misalignment through funny and tragic stories of remote consultations which were clearly inappropriate or unsafe (\u2018technology as farce\u2019). In 2021, the pandemic grumbled on and a backlog of unmet needs began to surface. The NHS was busier than ever; staff were exhausted; secondary care sought to redistribute work to primary care; and many key posts were unfilled because of early retirement, long-term staff illness and Brexit. In this context\u2014a system under extreme stress\u2014GPs used remote triage as a tool to control their workload. The media responded aggressively, running front-page campaigns to demand a better service from \u2018lazy\u2019 GPs who were depicted as being on the golf course while making occasional calls to sick patients on their smartphones. In this period, the focus of media stories was on the perceived lack of traditional face-to-face appointments and patients who had been \u2018fobbed off\u2019 with telephone calls (\u2018technology as cop-out\u2019). Over the course of 2 years, media narratives on technology-mediated consultations thus shifted from hopeful (reproducing a discourse of modernity and efficiency) to nostalgic (demanding a return to a golden era when patients could be seen \u2018properly\u2019). We discuss the implications of these depictions for the future of remote (and face-to-face) consultations.
\n \n\n \n \nBackground Following a large-scale, pandemic-driven shift to remote consulting in UK general practice in 2020, 2021 saw a partial return to in-person consultations. This occurred in the context of extreme workload pressures because of backlogs, staff shortages, and task shifting. Aim To study media depictions of remote consultations in UK general practice at a time of system stress. Design and setting Thematic analysis of national newspaper articles about remote GP consultations from two time periods: 13-26 May 2021, following an NHS England letter, and 14-27 October 2021, following a government-backed directive, both stipulating a return to in-person consulting. Method Articles were identified through, and retrieved from, LexisNexis. A coding system of themes and narrative devices was developed iteratively to inform data analysis. Results In total, 25 articles reported on the letter and 75 on the directive. Newspaper coverage of remote consulting was strikingly negative. The right- leaning press in particular praised the return to in-person consultations, depicting remote care as creating access barriers and compromising safety. Two newspapers led national campaigns pressuring the government to require GPs to offer in-person consultations. GPs were quoted as reluctant to return to an 'in-person by default' service (as it would further pressurise a system already close to breaking point). Conclusion Remote consultations have become associated in the media with poor practice. Some newspapers were actively leading the 'war' on general practice rather than merely reporting on it. Proactive dialogue between practitioners and the media might help minimise polarisation and improve perceptions around general practice.
\n \n\n \n \nBackground: Our research was based on the expressed need to evaluate the potential for group clinics to enhance care within the NHS for people with long-term conditions. Objectives: We aimed to explore the scope, feasibility, impact and potential scalability of group clinics for young adults with diabetes who have poor experiences of care and clinical outcomes. We applied a participatory approach to the entire research process, where appropriate. Setting: Four NHS trusts delivering diabetes care to young adults in ethnically diverse and socioeconomically deprived communities. Participants: We involved 135 young adults as participants in our research (73 at two intervention sites and 62 at two control sites). Methods: A realist review synthesised existing evidence for group clinics to understand \u2018what works, for whom, under what circumstances\u2019. Using the realist review findings and a scoping exercise, we used co-design to develop a model of group clinic-based care, which we then implemented and evaluated using primarily qualitative methods, with quantitative and costs analyses to inform future evaluations. Results: Young adults reported positive experiences from the group clinics. However, across the group clinics delivered, only one-third (on average) of those invited to specific clinics attended, despite substantial efforts to encourage attendance, and only 37 out of 73 (51%) participants attended any group clinics. Social learning helped the acquisition of new knowledge and normalisation of experiences. Group clinics met previously unreached emotional needs, and the relationships that formed between young adults, and between them and the staff facilitating the clinics, were key. Clinical staff delivered the clinics using a facilitatory approach, and a youth worker helped to ensure that the care model was developmentally appropriate. Existing organisational structures presented substantial challenges to the delivery of group clinics, and there was considerable hidden work required by the staff delivering them. Group clinics may augment one-to-one care but do not necessarily replace it. The average cost of each group clinic, per participant, was \u00a3127\u201358. Limitations: Engagement in co-design and the research process and participation in the group clinics was challenging, and limited our quantitative data analysis. These limitations had implications for the fidelity of the intervention and generalisability of our findings. During the research, we established that group clinics would not replace existing care, and that further work is required to understand the theoretical base of \u2018blended\u2019 models of care, and the potential of digital offers, before a definitive evaluation (a cluster-randomised trial) can be designed. Conclusions: Our findings show that young adults with diabetes, including those in deprived and ethnically diverse settings, have positive experiences of group-based care, and it may augment existing one-to-one care. However, engagement with group-based care is challenging despite the participatory design. Future work: Future research is needed to develop the group clinic model prior to definitive evaluation. Study registration: This study is registered as CRD42017058726 and ISRCTN83599025.
\n \n\n \n \nDuring crises (major events characterised by uncertainty, urgency and threat), society must make sense of rapidly unfolding events. This happens mainly through narrativising - depicting a setting, characters and a meaningful sequence of events and actions unfolding over time. In the early months of the pandemic, UK general practice shifted from face-to-face consultations to a remote-by-default model (telephone, video or e-consultation). This shift was initially widely accepted by press and public, but support waned after a politician declared that the change would be permanent. We invoke Burke's dramatistic pentad of act, scene, agent, agency and purpose to theorise findings from a detailed analysis of media coverage of the remote-by-default policy and reactions to it. We consider the 12 weeks from March to June 2020 (first lockdown, when remote-by-default services had just been introduced) and 1 week from late July 2020 (following the ministerial announcement). The initial introduction of remote consulting had strong narrative coherence in which all parts of the pentad were balanced: scene (a deadly virus threatening the country) aligned with act (lockdown, including avoiding face-to-face appointments unless essential), agents (the National Health Service and digital technology as heroic macro-actors), agency (general practitioners \"deployed') and purpose (to control the pandemic). The later period, however, was characterised by a mismatch between scene (a country emerging from lockdown and resuming normal life), act (imposition of the remote model), agent (a politician known for his enthusiasm for technology), agency (top-down directive) and purpose (modernisation). Whereas media narratives in the first period aligned with the genre of heroic adventure (suggesting a worthy battle, bravely fought), those of the second had characteristics of farce (something both comic and grotesque). We conclude that close reading of media narratives may surface potential misalignments between policy decisions and the context in which they must be implemented.
\n \n\n \n \nBackground Remote consulting was introduced quickly into UK general practice in March 2020 as an emergency response to COVID-19. In July 2020, \u2018remote-first\u2019 became long-term government policy. Aim To explore how this change was portrayed in national newspapers and how depictions changed over time. Design and setting Thematic analysis of newspaper articles referring to remote GP consultations from two time periods: 2 March\u201331 May 2020 (period 1) and 30 July\u201312 August 2020 (period 2). Method Articles were identified through, and extracted from, LexisNexis Academic UK. A coding system of themes and narrative devices was developed and applied to the data. The analysis was developed iteratively, amending the coding structure as new data were added. Results Remote consulting was widely covered in newspapers. Articles in period 1 depicted it positively, equating digital change with progress and linking novel technological solutions with improved efficiency and safety (for example, infection control) in a service that was overdue for modernisation. Articles in period 2 questioned the persistence of a remote-first service now that the pandemic was waning, emphasising, for example, missed diagnoses, challenges to the therapeutic relationship, and digital inequalities. Conclusion As the first wave of the pandemic came and went, media depictions of remote consulting evolved from an \u2018efficiency and safety\u2019 narrative to a \u2018risks, inequalities, and lack of choice\u2019 narrative. To restore public trust in general practice, public communication should emphasise the wide menu of consulting options now available to patients and measures being taken to assure safety and avoid inequity.
\n \n\n \n \nThe concept of \u2018peer support\u2019 has generated much interest in mainstream health services. In policy discourse, peer-based initiatives are often described as \u2018empowering\u2019 and seen as contributing to more \u2018democratic\u2019 and \u2018holistic\u2019 forms of care. Focusing on group clinics as one such example, this article challenges the assumption that peer-based initiatives represent a straightforward and unequivocal \u2018good\u2019 when embedded in clinical care. We draw on qualitative data from three studies (2016\u20132025), including 118 interviews and ethnographic observation in 59 in-person, remote, and hybrid group clinics for diabetes and menopause at 5 primary and secondary care sites in England. Adopting a sociomaterial lens, we uncover how different forms and practices of peerhood emerge (or not) in the circumstances through which these clinics are materialised. We show how biomedical artefacts (e.g. diabetes test results, menopause symptom lists) used as part of consulting play a key role in constituting forms of affiliation and differentiation between patients, in turn determining whether and what forms of peer \u2018support\u2019 (e.g. disciplinary, affirmative) are accomplished. We go on to explore how being presented as a peer as part of clinical consulting brings about new roles and responsibilities for patients, and introduce the term \u2018experiential caring\u2019 to denote a new mode of consulting that mobilises roles, practices, and subjectivities associated with peerhood.
\n \n\n \n \nBackground: General practice is facing an unprecedented challenge in managing the consequences of the pandemic. In the midst of a policy drive to balance remote and in-person service provision, substantial workload pressures remain, together with increasing prevalence of long-term conditions, and declining staff numbers and morale. To address these challenges, some practices in the UK have been delivering video and hybrid group consultations (VHGCs) providing clinical care to multiple patients at the same time. Despite positive initial findings and enthusiasm, there are still gaps in our understanding of the influence VHGCs have on patient experience, healthcare utilisation, quality, safety, equity and affordability. Objectives: To generate an in-depth understanding of VHGCs for chronic conditions in general practice, surface assumptions and sociotechnical dynamics, inform practice and extend theorisation. Methods: Mixed-methods, multi-site research study using co-design and participatory methods, from qualitative, quantitative and cost-related perspectives. WP1 includes a national, cross-sectional survey on VHGC provision across the UK. In WP2 we will engage patients and general practice staff in co-design workshops to develop VHGC models with emphasis on digital inclusion and equity. In WP3 we will carry out a mixed-methods process evaluation in up to 10 GP practices across England (5 sites already running VHGCs and 5 comparison sites). Qualitative methods will include interviews, focus groups and ethnographic observation to examine the experiences of patients, carers, clinical and non-clinical NHS staff, commissioners and policy-makers. Quantitative methods will examine the impact of VHGCs on healthcare utilisation in primary and secondary care, patient satisfaction, engagement and activation. We will also assess value for money of group and individual care models from a health economics perspective. Conclusions: We aim to develop transferable learning on sociotechnical change in healthcare delivery, using VHGCs as an exemplar of technology-supported innovation. Findings will also inform the design of a future study.
\n \n\n \n \nBackground Following several years of qualitative research, we have developed evidence-based guidance on setting up and conducting remote video consultations. Drawing on emerging evidence, we have also adapted the guidance to ensure accessibility and relevance for those using video calling during and beyond the COVID-19 pandemic. Findings This article describes the research underpinning this guidance material, with a focus on three key areas: (1) IT infrastructure, (2) organisational routines and workflows, and (3) interactional work of a video consultation. Our research highlights that such change is not merely about installing and using new technology. It involves introducing and sustaining major changes to a complex system with multiple interacting components. Conclusion If remote video consultations are to be adopted at scale, implementation will need to follow a socio-technical approach, continually adjusting the technology and work processes to become better aligned.
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