Decentring health and care networks : reshaping the organization and delivery of healthcare
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Decentring health and care networks : reshaping the organization and delivery of healthcare
（Organizational behaviour in health care / series editors, Jean-Louis Denis, Justin Waring, Paula Hyde）
Palgrave Macmillan, c2020
- hbk.
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Description and Table of Contents
Description
Networks have become a prominent template for public service governance. Often seen as an alternative to hierarchies and contracts, networks cross institutionalized organizational or sectoral boundaries to promote collaboration and the sharing of resources when addressing complex problems. Nowhere is this more the case than in the field of health services modernization and improvement.
Comprising unique empirical contributions, drawn primarily from the experience of the UK National Health Service (NHS), this edited collection develops a 'decentred' analysis of health and care networks. Contributors look beyond particular structures or patterns of governance and focus instead on the interpretation of the meaningful practices of policy actors as they encounter and enact policy instruments and structures. The approach offers a distinct form of analysis that deepens and enriches more traditional public policy accounts of network governance. It recognizes the influence of local history, highlights the influence of dominant economic, technical and corporate narratives, and acknowledges the continued influence of biomedical knowledge and professional expertise.
Offering practical insight for current and future service leaders about the challenges of implementing, managing and working within networks, this book draws out key messages for practitioners and researchers alike.
Table of Contents
- 1. Decentering Health and Care Networks: An introduction This chapter will introduce the collection by first setting on the historical policy context of networks and network governance in public policy and health policy. It will then introduce the principles of a decentred approach, focusing in particular in the interplay between history, dilemma and situated agency, and the concepts of narrative and discourse. After demonstrating the application of these ideas to health policy developments, in general, and health networks, in particular, the chapter will summarise the themes of the collection as contained within each contributing chapter, and will distil the cross-cutting themes, resulting in a summary statement of the main theoretical, empirical and practical contributions from the collection. This include, for instance, the importance of the temporal and spatial dimensions of networks, the persistence of resistance within and between networks, and the significance of framing, branding and badging networked activities. Authors: Mark Bevir, University of California, Berkeley Justin Waring, University of Nottingham 2. Putting Network Governance in its Place
- locating the projects of integrated health and social care As an approach to health service organisation resting on network ideals, integrated care has been widely adopted as an ideal in health service reforms. However, in promoting a vision of seamless coordination across professional and organisational boundaries, what is not often considered is how contested interpretations of geography and place shape projects of integrated care. This study presents qualitative data gathered during an evaluation of an integrated care project that took place between 2012-2015 in a metropolitan borough in the North of England. Findings are drawn from 45 qualitative interviews with project managers and front line health and social care staff as well as two years of participant-observations in project and locality team meetings. The findings highlight how the integrated care project involved attempts to create new localities of service provision across the borough shaped around policy and managerial imperatives for more joined-up, integrated and resource-efficient forms of care delivery. New localities were informed by geographical boundaries that contrasted with existing and historical understandings of place, and also struggled for dominance against parallel visions for regional health service reform. It is suggested that that rather than able to construct new cross-boundary social relations based on to a rationalised model of service provision, projects of integration are tightly entwined with the histories and meanings of the places in which they are enacted. Author: Simon Bishop is Associate Professor in Organisational Behaviour at Nottingham University Business School. HIs research is primarily focused on issues of public policy organisational change in healthcare and other public service organisations. Simon's PhD focused on organisational change during periods of public service outsourcing and partnership with the private sector. He has conducted several studies on new types of healthcare organisations and services, including Independent Sector Treatment Centres, integrated care providers and knowledge translations organisations. Simon's research seeks to examine the changing relationships between organisations following changes in public policy - for example those which encourage new forms of partnerships, supply and commissioning arrangements - and how this affects organisational management, work and employment. 3. Analysing the implementation of health care reforms: a decentred approach Juan I Baeza, King's College London Alec Fraser, London School of Hygiene and Tropical Medicine Annette Boaz, St. George's, University of London & Kingston University A bottom-up decentred lens was used to understand how local actors perceive reforms and use their agency to make sense of the change. The aim is to use this perspective to investigate the implementation of the 2007 stroke reforms in England. The stroke reforms can be characterised as a 'disruptive innovation' that it challenges existing stakeholders to rethink their current practices through the introduction of new ideas. These potential challenges to the prevailing arrangements, may conflict with the existing beliefs, ideas and traditions of local actors. We add to Bevir's decentred approach by exploring the roles of context, audit and leadership at the micro level. The paper highlights three key findings. Our micro level data highlight the importance of local context in both shaping and then adapting local actors' traditions and beliefs and thereby influencing their responses to the resulting dilemmas. These contextual influences are then important in understanding how a macro level policy directive is locally interpreted and implemented. Second, it was surprising to note that the introduction of greater surveillance in the form of audit seemed paradoxically attractive to senior clinicians who were able to use it to govern junior staff and to highlight the need for more resources in stroke care. Our data suggest that dilemmas are individually constructed, put simply, one person's dilemma can be another's opportunity. Lastly, in terms of leadership, the decentred approach allowed us to more deeply analyse the jurisdictional power of different professions and question the traditional view of medical supremacy in local leadership. Our data illustrate that stroke specialist nurses can be effective leaders and can be more influential than some senior doctors in implementing change at the local level. Authors: Dr Juan Baeza is senior lecturer in Health Policy at King's Business School. His research focuses on analysing health policy and health sector reform in the UK and internationally. 4. The contested practice of networking in healthcare management Paula Hyde, University of Manchester Networks have been celebrated for some time as vital to the operation of fluid, post-bureaucratic and knowledge-based organisations. However, much of the literature on governing networks prioritises research into formal networks and pays rather less attention to issues of informal and emergent networking. This is often accompanied by a structural-functionalist bias in network research, as networks are ascribed with a self-evident purpose which may be measured and evaluated. The consequence is a neglect of the meaning and practice of networking, as membership, position and participation in networks are taken for granted. We seek to address this gap by exploring, ideographically, the meaning ascribed to informal networking among healthcare managers, and various tensions which result. Using qualitative data from a three-year study of UK healthcare organisations, we explore practices of networking across three defined managerial groups - functional, general and clinical. Our findings highlight the challenges facing attempts to govern such networks. Author: Paula Hyde is Professor of Organisation Studies at Birmingham Business School, University of Birmingham and holds a visiting position at Macquarie University, New South Wales, Australia. She is a Fellow of the Academy of Social Sciences. Paula is one of the leading figures in the field of organisation studies in health and social care both nationally and internationally. Her standing in the field is well established and widely acknowledged both through extensive engagement with public and policy audiences and through regular engagement with the academic community worldwide. Paula is series editor for the Palgrave Macmillan monograph series on Organisational Behaviour in Healthcare. She recently published refereed articles in journals such as
- Gender, Work and Organization, Human Relations, Human Resource Management, Industrial and Labor Relations Review, International Journal of Human Resource Management, Journal of Social Policy, Management Learning, Organization Studies, Work, Employment and Society. She has also published 5 books on health care management, organisation and delivery. 5. Buddies and Mergers: decentring the performance of healthcare provider partnerships Ross Millar, Robin Miller and Russell Mannion Health Services Management Centre, University of Birmingham Faced with increasingly complex population care needs, predicted societal trends, and diminishing financial resources, healthcare systems are currently engaged in a series of network governance arrangements to support and sustain service delivery. In England, the Conservative government since 2015 has introduced new models of care with initiatives promoting the integration health and social care as well as greater co-ordination and standardisation across care systems and networks. Better partnership working is also emphasised with regulatory interventions supporting mergers and acquisitions between NHS providers to improve the quality and sustainability of local services. While a range of research and evaluation continues to document the effectiveness of these network formations, there remains a distinct lack of analysis regarding the ideas, beliefs, and practices surrounding these endeavours. The promotion of partnership working between NHS providers remains a notable case in point as the motivations and experiences of such collaborative working often lacks sufficient in depth analysis. The purpose of this chapter is to present a decentred account of current approaches to inter organisational partnership working across different NHS provider contexts. Drawing on qualitative interviews with those identified in boundary spanning roles across five different NHS provider partnerships, the findings identify and present how partnerships were connected to narratives of leadership, management, trust, and intelligence gathering. The chapter goes on to argue that these narratives of partnership working reflect 'expressions of cultural performance' in the way they depict a series of entrepreneurial activities intended to stabilise, expand, and improve service delivery within the context of diminishing financial resources and regulatory performance management frameworks. While these partnerships were in many ways supported, findings highlight the fragility and uncertainty surrounding these formations as partnership working created anxieties and fears associated with the lack of planning, infrastructure, and oversight of activities. Through its decentred analysis, the chapter looks to extend current understandings and interpretations of these policy developments by drawing attention to the performative dimensions of partnership working within a policy context increasingly reliant on network governance frameworks and discourses. Authors: Dr Ross Millar is a Senior Lecturer in Health Care Policy and Management. He has extensive experience of healthcare organisational and policy research into quality improvement, governance, and organisational change. Ross has published across a range of journals and has led and co-led funded projects from the National Institute for Health Research, Department of Health, and the Health Foundation in the UK. Dr Robin Miller is a Senior Fellow at the Health Services Management Centre. He leads on a variety of applied research projects within health and care, with a particular focus on evaluating and learning from change initiatives. Current projects include local evaluations of new models of care programme. Robin is a Senior Associate of the International Federation of Integrated Care, an advisory group member of the European Primary Care Network, and a Fellow of the School for Social Care Research. Professor Russell Mannion holds a Chair in Health Systems at the University of Birmingham with more than 30 years of experience of health services research. His areas of interest include evaluation of health systems reform, patient safety, quality improvement, and performance measurement and management. Russell has published extensively and has led and co-led a variety of funded projects, including 23 NIHR grants 6. Pastoral practices in the governmentalisation of practical norms in a Kenyan clinical network Gerry McGivern, University of Warwick Jacinta Nzinga, University of Warwick Mike English, University of Oxford 'Practical norms' are informal, semi-visible and widespread norms that deviate from official or professional norm, which significantly affect, and often undermine, health care quality and delivery and public services more generally in many African counties. We explain how a clinical network developed an evidence-based governmentality, which modified practical norms in a group of Kenyan district hospital. We trace the development of this evidence-based governmentality and analyse how it transformed local practical norms in the Kenyan health care context. We highlight the key role of clinical 'pastors', pastoral power and pastoral practices, within this process. We finally suggest that the analytic concepts of practical norms, evidence-based governmentality, pastoral power and pastoral practices may elucidate and explain ways of improving health care in other Low and Middle Income Counties (LMICs) and beyond. Authors: Gerry McGivern is Professor of Organisational Analysis and Head of the Organisation and Human Resource Management at Warwick Business School, UK. His research focuses on organisation, management, leadership, regulation, professionals, knowledge and practice in health care. He has led large funded research projects, published in leading international social science and management journals, and co-authored 'Making Wicked Problems Governable: The Case of Managed Networks in Health Care' (Oxford University Press, 2013) and 'The Politics of Management Knowledge in Times of Austerity (Oxford University Press, 2018). Dr Jacinta Nzinga is health system researcher with a focus on social science research working with the Health Services Research Group, Kemri-Wellcome Trust Research Programme. Her research work and interests are in the areas of management of human resources for health, health policy analysis and the interpretive analysis of their implementation, organizational change and implementation of innovation, organizational behavior and clinical leadership in health care. Mike English is Professor of Global Health in the Nuffield Department of Medicine, University of Oxford. He is a UK trained paediatrician who has worked in Kenya for over 20 years supported by a series of Wellcome Trust fellowships. He works as part of the KEMRI-Wellcome Trust Research Programme (KWTRP) in collaboration in Kenya with the Ministry of Health, the University of Nairobi, and with a wide set of international collaborators. 7. Situated practices of human and non-human networks in the delivery of emergency and urgent care services Catherine Pope, Southampton University Information and communication technologies are an important driver for network-based forms of governance (Castells 1996/ Ferlie et al 2011). These technologies include computer decision support systems (CDSS) and software algorithms deployed to improve, optimise and manage health service delivery as in the case presented here, the NHS Pathways CDSS. This CDSS operates an algorithm, drawing on an extensive repository of clinical information to support NHS urgent and emergency care telephone triage services. Call handlers using the CDSS make decisions about whether the caller needs an immediate ambulance or can wait to see a general practitioner, and they can also provide advice about self-care. This chapter presents data from two large, comparative ethnographic studies of this CDSS which provide data from over 850 hours of observation, surveys of 700 staff and interviews and focus group data from over 100 staff. Here I explore the interpretive gap between the promise of digital governance and the attempt to bring this computer technology into use as a way of managing demand for care. The chapter argues that, at its heart the CDSS operates with a model of perfect governance, premised upon the idea that triage is a rational, rule governed, standardisable process. The reality, as we will see, is that this vision is thwarted, adapted, and resisted in the everyday situated practices and networks of care that involve human and non-human actors. The chapter presents a thematic analysis of a series of assumptive rules about disease presentation and decision-making to demonstrate how digital governance is resisted. Author: Catherine Pope is Professor of Medical Sociology within Health Sciences, University of Southampton where she leads the Emergency and Urgent Care (EmU) research group. Her research examines health care work and the organisation and delivery of health services and this has entailed recent work on NHS 111 urgent care services, the role of evidence in GP commissioning and studies of ambulance services. She has contributed to major national evaluations of NHS treatment centres, Walk-in Centres and Access to General Practice, and was an invited methodological expert to the Chantler independent review of plain paper packaging of tobacco. Catherine has played a leading role in developing qualitative methods and evidence synthesis in health services research and is co-author of significant books and journal papers on these methods. 8. Networking for health, networking for wealth: a study of English health innovation policy in practice Jean Ledger, University College London This chapter explores the translation of health innovation policy into the English NHS through the formation of regional Academic Health Science Networks (AHSNs). The networks, founded against a backdrop of economic austerity, have been tasked with delivering a central government mandate to support population health, wealth creation and innovation adoption in the NHS. After briefly reviewing this policy background, we draw on empirical data to understand the evolving dynamics during the early development of AHSNs (2013-2016), such as how network leaders attempted to manage ambiguities and tensions in central government policy, resulting in a high degree of local experimentation. It is suggested that examination of local-level interpretations of policy ambitions around health and wealth, situated within regional contingencies, reveals tangible tensions between central network governance and local network autonomy. We conclude that the gradual progress of these networks, and their early struggle to demonstrate 'wealth creation' and innovation adoption in measurable terms, is unsurprising given that a period of 'network anchoring' was first required to build the expertise, relationships and collaborations necessary to achieve policy goals and interpret their meaning across different contexts. The evolution of these policy networks, focused on innovation, therefore reveals extensive localism running alongside a strong pull from central government towards meeting broad economic and health policy goals. The AHSNs gradually worked more strategically over time, as a national entity, to achieve greater uniformity as a policy tool and manage these tensions, eventually influencing central government policy. Author: Jean Ledger is a social scientist and researcher based at the Department of Applied Health Research, University College London. Her research interests are focused on health policy, public management, and the uptake of research, evidence and innovation in health care to improve quality and service delivery. She specialises in qualitative research methods and has undertaken a number of large-scale projects and evaluations funded by the UK's National Institute for Health Research. 9. Decentring collaborative healthcare research networks: the tensions between technocracy and coproduction. Rob Vickers, Charlotte Overton, Bridget Roe and Justin Waring University of Nottingham . The effective translation of applied health research into practice is a major dilemma for healthcare systems. Recent attempts to promote the spread of healthcare innovation in England has focused upon inter-organisational collaborations and networks. Drawing on a decentred theory of governance (Bevir, 2013), we locate these in a setting of situated agency and national and local traditions. Utilising learning and experience from the English National Health Service (NHS). This chapter then addresses the tensions between technocracy and coproduction in the way collaborative healthcare research networks manifest in practice. Existing research indicates the need for 'technocratic' expertise to access new data to fuel discovery and inform evidence-based practice (EBP). While, coproduction, focusing on the drive for collective working to improve processes by creating user-led, people-centred health and care services, is also envisaged as central to the improvement of health and care outcomes. However, there is little evidence about the interdependence and conflicts between these two approaches. Consequently, the aim of this chapter is to employs Decentred theory to explore the ways in which collaborative healthcare research networks are made, and remade, through the activities of the individuals who compose them to resolve conflicts. Authors: Rob Vickers read Politics and Economics at Loughborough University (1994), followed by an MSc in Social Science Research Methods at Nottingham Trent University (2000). After a pre-doctoral research post working on an Economic and Social Research Council project, he completed a doctorate in Politics (2011) on 'high cost political participation'. He held post-doctoral research posts at the International Centre for Guidance Studies, University of Derby (2014) and Nottingham Trent University, where he worked on the Outstanding Teaching, Learning and Assessment project (2015). After which, he led on the evaluation of the National Collaborative Outreach Project, University of Lincoln (2017). Rob is currently a Research Fellow at the Centre for Health Innovation, Leadership and Learning (CHILL), Nottingham University Business School, working on knowledge management methods and performativity. Charlotte Overton is Researcher in Residence in the East Midlands Patient Safety Collaborative and Research Associate in the Centre for Health Innovation Leadership and Learning, Nottingham University Business School. Her previous role was working on the Implementation of Evidence and Improvement theme within the Collaboration for Leadership in Applied Health Research and Care East Midlands Charlotte's PhD was a qualitative multi-site case study exploring the implementation of the sepsis care bundle, drawing on theory from Science and Technology Studies to inform Implementation Science. Charlotte's research interests are in the use of social science in patient safety and quality improvement, evaluation, implementation science and ethnography. Charlotte is also a practicing acute care nurse. 10. Sharing stories or co-constructing practice? Challenges to undertaking and researching innovation using evidence from the English NHS Simon Turner, University of Manchester A network theory of governance situates learning processes in the sharing of stories (which we might call 'agency') against a background of traditions and norms (which could be seen as 'structure'). This perspective has implications for both the conceptualisation and study of learning and innovation as a distributed process within organisations. This chapter explores, and develops further, the role of stories in innovation by drawing on aspects of practice theory, in particular, John Shotter's concept of 'dialogical practice' which explores the co-construction of agency through dialogue which represents a 'third' way of knowing that does not belong to any one individual, but is a shared, creative act. If such stories are co-constructed through interaction, rather than being formulated and shared by individuals, this has implications for how we conceptualise agency in learning and innovation processes. When seen dialogically, stories can be seen as enduring or ephemeral, and support or impede change depending on the networks though which they are co-constructed. This chapter explores this idea using ethnographic evidence from an NHS provider of specialist eye services managing an organisational network of clinics. It examines the planning and implementation of innovation through this network and the ways in which the co-construction of stories, and the potential for both creativity and breakdown as they unfold, influence the innovation process. This perspective also has practical implications for the conduct of ethnography for inquiring into innovation processes through stories. Author: Simon Turner is Senior Lecturer in Health Policy and Organisation in the Centre for Primary Care at the University of Manchester. He previously held research positions at University College London, King's College London, the London School of Hygiene & Tropical Medicine, and the University of Cambridge. His research interests lie in the application of social science theory and methods (particularly ethnography) to the study of the organisation and improvement of health services. His research has been published in core social science journals including Social Science & Medicine, Public Administration, Sociology of Health and Illness, Socio-Economic Review, Implementation Science, and Journal of Economic Geography. He is leading a national study funded by the Health Foundation on the role of evidence in decision-making on innovation (Mar 2016 - May 2018).
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