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Healthcare policy frequently invokes notions of cultural change as a means of achieving improvement and good-quality care. This Element unpacks what is meant by organisational culture and explores the evidence for linking culture to healthcare quality and performance. It considers the origins of interest in managing culture within healthcare, conceptual frameworks for understanding culture change, and approaches and tools for measuring the impact of culture on quality and performance. It considers potential facilitators of successful culture change and looks forward towards an emerging research agenda. As the evidence base to support culture change is rather thin, a more realistic assessment of the task of cultural transformation in healthcare is warranted. Simplistic attempts to manage or engineer culture change from above are unlikely to bear fruit; rather, efforts should be sensitive to the complexity and highly stratified nature of culture in an organisation as vast and diffuse as the NHS. This title is also available as Open Access on Cambridge Core.
NHS Foundation Trust (FT) hospitals in England have complex internal governance arrangements. They may be considered to exhibit meta-regulatory characteristics to the extent that governors are able to promote deliberative values and steer internal governance processes towards wider regulatory goals. Yet, while recent studies of NHS FT hospital governance have explored FT governors and examined FT hospital boards to consider executive oversight, there is currently no detailed investigation of interactions between these two groups. Drawing on observational and interview data from four case-study sites, we trace interactions between the actors involved; explore their understandings of events; and consider the extent to which the proposed benefits of meta-regulation were realised in practice. Findings show that while governors provided both a conscience and contribution to internal and external governance arrangements, the meta-regulatory role was largely symbolic and limited to compliance and legitimation of executive actions. Thus while the meta-regulatory ‘architecture’ for governor involvement may be considered effective, the soft intelligence gleaned and operationalised may be obscured by ‘hard’ performance metrics which dominate resource-allocation processes and priority-setting. Governors were involved in practices that symbolised deliberative involvement but resulted in further opportunities for legitimising executive decisions.
In the context of an austere financial climate, local health care budget holders are increasingly expected to make and enact decisions to decommission (reduce or stop providing) services. However, little is currently known about the experiences of those seeking to decommission. This paper presents the first national study of decommissioning in the English National Health Service drawing on multiple methods, including: an interview-based review of the contemporary policy landscape of health care decommissioning; a national online survey of commissioners of health care services responsible for managing and enacting budget allocation decisions locally; and illustrative vignettes provided by those who have led decommissioning activities. Findings are presented and discussed in relation to four themes: national-local relationships; organisational capacity and resources for decommissioning; the extent and nature of decommissioning; and intended outcomes of decommissioning. Whilst it is unlikely that local commissioners will be able to ‘successfully’ implement decommissioning decisions unless aspects of engagement, local context and outcomes are addressed, it remains unclear what ‘success’ looks like in terms of a decommissioning process.
An in-depth analysis of the NHS reforms ushered in by UK Coalition Government under the 2012 Health and Social Care Act. Essential reading for those studying the NHS, those who work in it and those who seek to gain a better understanding of this key public service.
Quality and safety are defined and measured in different ways by academics, commentators and agencies, while the relationship between them are viewed in different ways (Leatherman and Sutherland, 2003; 2008; Raleigh and Foot, 2010; Vincent et al, 2013). The US Institute of Medicine (IoM, 2001) provides a ‘long list’ that healthcare is high quality if it is safe, effective, timely, person-centred, equitable and efficient (Raleigh and Foot, 2010; Gardner, 2015), but this has often been reduced to a ‘short list’ of three dimensions. Raleigh and Foot (2010) write that while the definitions of quality vary in different settings, some themes – safety, effectiveness and patient experience – are common to most quality frameworks (for example, IoM, 2001; DH, 2008; NQB, 2013), and are regarded as the three pillars of quality in healthcare (Doyle et al, 2013; NQB, 2013; Swinglehurst et al, 2015).
As Donaldson and Darzi (2012) put it, however, in the first 50 years of the NHS, quality was implied but not made explicit (but see Thorlby and Maybin, 2010), perhaps assumed not to be an issue due to the ‘best in the world’ mantra (see Chapters 3 and 17). Issues of quality and safety in healthcare became more central about the turn of the twenty-first century, with important reports in the UK and the USA (Kohn et al, 1999; IoM, 2001; DH, 2000b).
This chapter examines the three pillars of safety, effectiveness and patient experience (compare DH, 2008). After a brief review of earlier periods, it focuses on reforms in England under the Coalition government. It then explores the impact of reforms on quality and safety, providing a wider comparative perspective.
Historical background: quality in the NHS 1948–97
Although rarely explicitly addressed, there were occasional concerns over quality in the early NHS. Vincent et al(2013) provide a chronology of events related to patient safety in England in the twentieth century including the Confidential Enquiry into Maternal Deaths (1952), the Safety in Drugs Committee (1963), and inquiries into failures at Alder Hey Hospital; Ashworth Secure Hospital, and enquiries into doctors – Rodney Ledward and Harold Shipman (1990s).
Evaluating the state of the NHS in its seventh decade is the subject of this book. It specifically addresses the programme of reforms undertaken by the Coalition government (2010–2015) in England. Our particular focus is from a policy perspective. This book adds to the growing body of knowledge about the design and implementation of major health service reforms in the UK (for example, Greener et al, 2014). Although it takes as its specific focus the five year period of the Coalition government (between the Conservatives and the Liberal Democrats; 2010–2015), it sets these reforms within a wider social, political, financial and organisational context of reforms to the NHS over the previous 25 years.
When a major reform of the National Health Service is announced, it is often claimed to be the most significant, the most far-reaching, the most consequential re-organisation that has taken place since its inception in 1948 (for example, Margaret Thatcher's foreword to Working for Patients, Secretaries of State, 1989). Indeed this may be so. Yet the reforms of the Coalition government, whose apogee was the 2012 Health and Social Care Act, can truly meet this oft-quoted claim. In a speech in November 2010, David Nicholson, the then NHS Chief Executive, referred to these reforms as ‘such a big change management, you could probably see it from space’ (quoted in Greer et al, 2014, 3). Moreover, not only were they major health policy reforms in their own right, but they built on a series of successive pro-market reforms which date back to the mid-1980s.
Yet the scale of re-organisation was not mentioned in the Conservative party's manifesto (for the 2010 general election); instead, its emphasis was on decentralisation of power to clinical staff (including GPs) and enhancing autonomy for NHS providers. For example: ‘We will decentralise power, so that patients have a real choice. We will make doctors and nurses accountable to patients, not to endless layers of bureaucracy and management’ (Conservative Party, 2010, 45).
Nor did the Coalition partner, the Liberal Democrats mention largescale NHS reform in their 2010 election manifesto. For example: ‘We all know that too much precious NHS money is wasted on bureaucracy, and doctors and nurses spend too much time trying to meet government targets’ (Liberal Democrats, 2010, 40).
I used to pore over the latest offerings from various highly reputable academic or scholarly quarters, and find nothing of any real practical help. (Tony Blair, cited in Powell, 2011)
During the 2000s there was a great deal of rhetoric about evidencebased policy and evidence-based policy-making (Davies et al, 2000; Perkins et al, 2010). However, policy and policy-making often appear to be rather more based on the existing ideas (or even prejudices or ideologies) of those in positions of power rather than on research evidence. And there are several reasons for this.
Policy-makers may believe they already know what needs to be done, and so do not need to examine what research says. Equally, those in positions of power may find research inaccessible in terms of its place of publication, or that it is written in dense, academic language they find difficult to understand. They may also find research to be too equivocal, too concerned with trying to consider both sides of a problem than coming to a conclusion or solution that they can get on with turning into a workable policy. Policy-makers may also have strong views about what needs to be done by government, regardless of what researchers are telling them, often seeming to put their own political goals ahead of research, and their ideology ahead of evidence.
When looking back at NHS reorganisations, it does seems to be the case that since the 1980s policy-makers have been unable to resist changing organisational structures, not even waiting to see if the last changes they attempted to put into place had worked or hadn’t. Secretaries of State for Health have sometimes seemed as if they are intent on leaving their own impression on the NHS organisation without considering whether what they are planning to change has any real chance of working.
From the perspective of academics and researchers, on the other hand, policy-makers and politicians often appear to have short attention spans and do not want to engage with the complexities of the area they are trying to change. Politicians can sometimes look as if they have decided what needs to be done without looking at lessons from the past or from other countries.