Does integrated governance lead to integrated patient care? Findings from the innovation forum

Good integration of services that aim to reduce avoidable acute hospital bed use by older people requires frontline staff to be aware of service options and access them in a timely manner. In three localities where closer inter‐organisational integration was taking place, this research sought patients’ perceptions of the care received across and within organisational boundaries. Between February and July 2008, qualitative methods were used to map the care journeys of 18 patients (six from each site). Patient interviews (46) covered care received before, at the time of and following a health crisis. Additional interviews (66) were undertaken with carers and frontline staff. Grounded theory‐based approaches showed examples of well‐integrated care against a background of underuse of services for preventing health crises and a reliance on ‘traditional’ referral patterns and services at the time of a health crisis. There was scope to raise both practitioner and patient awareness of alternative care options and to expand the availability and visibility of care ‘closer to home’ services such as rapid response teams. Concerns voiced by patients centred on the adequacy of arrangements for organising ongoing care, while family members reported being excluded from discussions about care arrangements and the roles they were expected to play. The coordination of care was also affected by communication difficulties between practitioners (particularly across organisational boundaries) and a lack of compatible technologies to facilitate information sharing. Finally, closer organisational integration seemed to have limited impact on care at the patient/practitioner interface. To improve care experienced by patients, organisational integration needs to be coupled with vertical integration within organisations to ensure that strategic goals influence the actions of frontline staff. As they experience the complete care journey, feedback from patients can play an important role in the service redesign agenda.     

Formal and informal inter‐organizational coordination: How nurses adapt in complex pathways

With the coordination of health care services becoming increasingly complex, the challenges of fragmentation cannot be solved by administrative restructuring alone. Attention must also be given to the coordination practices of professional groups, and, in this respect, the nursing profession is a particularly interesting case. Based on a qualitative case study of Danish nurses in hospital, municipality, and general practice, this article addresses the following question: How does the nursing profession practice formal and informal inter‐organisational coordination in complex pathways, and what is the interplay between the 2 types of coordination? The findings contribute to our knowledge of coordination at the operative level of health care by identifying specific informal practices in inter‐organisational coordination and by showing how informal coordination is activated to support formal coordination in a concurrent organisational and professional ambition of integration. The nurses studied here proved very loyal to formal inter‐organisational coordination mechanisms, prioritising them as first choices of action. When formal procedures were found insufficient, however, the nurses temporarily switched to informal coordination. This was triggered by random encounters with fragmentation, a strong professional engagement in making things work in the interest of the patient, and a constant striving to be on top of things. Informal inter‐organisational coordination is broken down into supplementary and by‐passing practices, and 4 specific by‐passing practices are identified. The discussion offers insight into how a lack of agency related to formal inter‐organisational coordination can be related to negotiated settlements, and informal coordination is considered in terms of “rule bending” within complex systems.     

Defining hospital's internal boundaries. An organisational complexity criterion

The aim of this paper is to provide empirical evidences supporting the definition of hospital wards’ boundaries in organisational designing processes, by suggesting services aggregation criteria that are focused on organisational complexity. In order to test the research hypotheses, a panel data analysis was conducted on Lombardy hospitals in Italy. Information was gathered both from administrative records – aggregated at in-patient ward level – and general registry offices. The results highlight that the wards offering integrated services perform better than those that are more specialised. However, for growing levels of within-complexity, the positive effects of formal integration between wards tend to reduce. Some guidelines for practitioners engaged in defining hospitals’ organisational structures can be drawn from the empirical analysis.     

The mundane ailment and the physical self: analysis of the social psychology of health and illness

Using interview data from adult men and women who participated in an ongoing study of self-care, the research focused on the experience of mundane ailments as a promising topic for research in the social psychology of health and illness. Phenomenological analysis of respondents' accounts of everyday ailments generated concepts of 'the physical self', which expands interactive or dramaturgical concepts, and 'the health biography'. These concepts, when linked to analysis of interaction lead to a more dynamic sociology of health, illness, care and cure.     

Integrated care in the emergency department: a complex adaptive systems perspective

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emergency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at the boundaries of the ED and other hospital departments and organizations whose services emergency clinicians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, and patients' needs across this journey is challenging. The journey is usually accounted for in a linear way - as a "continuity of care" problem. In this paper, we instead conceptualize integrated care in the ED using a complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which other departments and units outside of the ED are integrated, and appropriately described, using CAS concepts and language. One year of ethnographic research was conducted, combining observation and semi-structured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CAS approach to be salient to analyzing integrated care in the ED because the processes of categorization, diagnosis and discharge are primarily about the linkages between services, and the communication and negotiation required to enact those linkages, however imperfectly they occur in practice. Emergency clinicians rapidly process large numbers of high-need patients, in a relatively efficient system of care inadequately explained by linear models. A CAS perspective exposes integrated care as management of the patient trajectory within porous, shifting and negotiable boundaries.     

A holistic client-centred program for vulnerable frequent hospital attenders: cost efficiencies and changed practices

Objective: A small percentage of Australians frequently attend hospital emergency departments (ED) with potentially avoidable health crises. These individuals are termed ‘vulnerable’ due to their complex health and social needs. When these needs are unmanaged, unnecessary ED and hospital‐admission costs are incurred. A holistic community‐based program was developed to engage a cohort of vulnerable individuals in strategies to improve their health and health behaviours, and health service use. Methods: A purposive sample of frequent ED attendees was identified in one Australian metropolitan health region. Core program elements included working with clients within their environment, problem solving, empowerment, education, goal setting and mentoring. Evaluation data included services provided for, and time spent with, clients; hospital admission and emergency department attendances and related costs; client engagement data; mental health measures; client stories and participant interviews. Results: Data was analysed from 37 clients. On average, staff spent 34 hours with each client, costing approximately $1,700 each. Significant improvements resulted in client health and health behaviours. Crisis emergency department and inpatient admissions decreased, and planned outpatient clinic use increased. Conclusion: Low‐cost community‐based intervention for frequent ED attendees has the potential for significant tertiary hospital savings.     

Spanning boundaries in pursuit of effective knowledge sharing within networks in the NHS

PURPOSE: The purpose of this paper is to examine power asymmetries in the delivery of genetics healthcare that inhibit knowledge sharing across sector, organisational and professional boundaries. DESIGN/METHODOLOGY/APPROACH: The paper is a longitudinal comparative case study approach, which encompasses semi-structured interviews and observation. FINDINGS: The paper finds politics to be significant in its influence on knowledge sharing across sector, organisational and professional boundaries, but this can be mediated by attending to human and social aspects of the context in which knowledge sharing was expected to take place. RESEARCH LIMITATIONS/IMPLICATIONS: The paper encourages research that evaluates the effect of increased emphasis on human and social aspects of organisational change in pursuit of the "dream" of spanning boundaries and improving knowledge sharing within the NHS. PRACTICAL IMPLICATIONS: The paper shows that structural change appears to be of limited effect in promoting knowledge sharing. Organisational and individual development, career management and performance systems are worthy of attention for the purpose of managing knowledge. ORIGINALITY/VALUE: The paper exposes this assumption as managerialist. Policy-makers assume that professionals are willing and able to share knowledge when delivering healthcare through networks.     

Experiences from the frontline: An exploration of personal advisers’ practice with claimants who have health‐related needs within UK welfare‐to‐work provision

Recent UK welfare reforms have been less successful than expected by the Government in supporting unemployed people with long‐term illness into work. Frontline workers remain a core element of the new welfare‐to‐work machinery, but operate within a changed organisational and policy landscape. These changes raise important questions regarding whether and how claimants’ health‐related barriers to work are considered. This paper examines the UK welfare‐to‐work frontline worker's role with claimants who have long‐term illness. Fieldwork observations in three not‐for‐profit employment support services and semi‐structured interviews with 29 participants (claimants, frontline workers, healthcare professionals and managers) were conducted between 2011 and 2012. Participant observation of the wider welfare‐to‐work arena was initiated in 2009 and continued until 2013. A qualitative methodology drawing on ethnographic principles was adopted. Thematic analysis of the data was carried out. The findings show that the frontline worker plays a key role in assessing and addressing claimants’ health‐related barriers to work. Two important health‐related role dimensions were identified: a health promoter role which involved giving health promotional advice to claimants about their general health; and a health monitor role which involved observing and questioning claimants about their general health. Frontline workers’ practice approaches were shaped by organisational and individual factors. Integration between the National Health Service and employment support services was limited, and the findings suggested improvements were required to ensure an adequate response to claimants’ health‐related needs to support their journey into work.     

Bridging a gap: the (lack of a) sociology of oral health and healthcare

This article provides an historical review of international research related to sociology and oral health and healthcare. I begin by considering the relevance of the mouth and oral health to social interactions and physical health, and outline existing inequalities in oral health and healthcare experiences. The paper examines critically some of the existing published research in the field – considering both what might be described as sociology of oral health and healthcare and sociology in oral healthcare – and demonstrates the dearth of sociological research related to this subject compared to other areas of interest within the field of sociology of health and illness. I conclude by suggesting some ways in which this area could be expanded and developed further. I suggest that sociological analyses of how individuals experience, understand and manage their mouth and oral health, can add to and enhance the broader field of the sociology of health and illness. Further, examining experiences and provision of oral healthcare may provide sociology with a new opportunity to explore the neglected field of private healthcare, but also to engage with health policy makers who seek to address oral healthcare needs.     

Architecture and health care: a place for sociology

Sociologists of health and illness have tended to overlook the architecture and buildings used in health care. This contrasts with medical geographers who have yielded a body of work on the significance of places and spaces in the experience of health and illness. A review of sociological studies of the role of the built environment in the performance of medical practice uncovers an important vein of work, worthy of further study. Through the historically situated example of hospital architecture, this article seeks to tease out substantive and methodological issues that can inform a distinctive sociology of healthcare architecture. Contemporary healthcare buildings manifest design models developed for hotels, shopping malls and homes. These design features are congruent with neoliberal forms of subjectivity in which patients are constituted as consumers and responsibilised citizens. We conclude that an adequate sociology of healthcare architecture necessitates an appreciation of both the construction and experience of buildings, exploring the briefs and plans of their designers, and observing their everyday uses. Combining approaches and methods from the sociology of health and illness and science and technology studies offers potential for a novel research agenda that takes healthcare buildings as its substantive focus.     

Factors influencing the willingness of community service organisation staff to provide smoking cessation support: a qualitative study

Objective : This study aimed to explore factors influencing community service organisation (CSO) staff members’ willingness to provide tobacco cessation support to clients experiencing disadvantage. Methods : Face‐to‐face semi‐structured interviews were conducted with 29 staff members from seven services in the alcohol and other drugs, homelessness, and mental health sectors in Western Australia. Results : The primary barriers to providing cessation support were believing that addressing smoking was not a priority relative to other issues, being a current smoker, and the lack of a formal tobacco cessation program within the organisation. Factors that appeared to be most influential in enabling the delivery of cessation support were organisational processes requiring staff to routinely ask clients about tobacco use, confidence to provide support, and being a past smoker. Conclusions : The introduction of organisational procedures that include routine cessation care should be of high priority in CSOs to help reduce smoking rates among clients. Staff may also benefit from receiving training in the provision of cessation support and education about the importance and feasibility of addressing smoking concurrently with other issues. Implications for public health : The results may inform future efforts to increase the delivery of cessation care to groups of people experiencing disadvantage and comorbidity.     

‘Don’t think that we die from AIDS’: Invisibilised uncertainty and global transgender health

The invisibilisation of social groups in health research and survey data is a source of medical uncertainty, long seen as a hallmark of the medical field. However, scholarship has not thoroughly assessed how medical uncertainty is structured by state-level processes and global health agendas, especially for people beyond the Global North. This article introduces invisibilised uncertainty as a type of medical uncertainty structured by global organisational and state-level priorities, which can invisibilise social groups and health problems from research and data collection, exacerbating medical uncertainty and health disparities for people worldwide. Based on 14 months of fieldwork in Thailand and in-depth interviews with 62 participants, the article illuminates how state-level processes and global clinical research agendas have structured knowledge gaps and uncertainties for Thai transgender women. As omissions in health research and data collection become embodied on a world scale, the article expands our understandings of how gendered health disparities are structured nationally and globally. It advances a sociology of medical ignorance by analysing the uneven landscape of holistic transgender health research, parsing how institutional dynamics can prioritise or invisibilise people and health issues in research and data, and structure uncertainties.     

Institutional logic in self‐management support: coexistence and diversity

The prevalence of chronic conditions in Europe has been the subject of health‐political reforms that have increasingly targeted collaboration between public, private and voluntary organisations for the purpose of supporting self‐management of long‐term diseases. The international literature describes collaboration across sectors as challenging, which implies that their respective logics are conflicting or incompatible. In line with the European context, recent Norwegian health policy advocates inter‐sectorial partnerships. The aim of this policy is to create networks supporting better self‐management for people with chronic conditions. The purpose of our qualitative study was to map different understandings of self‐management support in private for‐profit, volunteer and public organisations. These organisations are seen as potential self‐management support networks for individuals with chronic conditions in Norway. From December 2012 to April 2013, we conducted 50 semi‐structured interviews with representatives from relevant health and well‐being organisations in different parts of Norway. According to the theoretical framework of institutional logic, representatives’ statements are embedded with organisational understandings. In the analysis, we systematically assessed the representatives’ different understandings of self‐management support. The institutional logic we identified revealed traits of organisational historical backgrounds, and transitions in understanding. We found that the merging of individualism and fellowship in contemporary health policy generates different types of logic in different organisational contexts. The private for‐profit organisations were concerned with the logic of a healthy appearance and mindset, whereas the private non‐profit organisations emphasised fellowship and moral responsibility. Finally, the public, illness‐oriented organisations tended to highlight individual conditions for illness management. Different types of logic may attract different users, and simultaneously, a diversity of logic types may challenge collaboration at the user's expense. Moral implications embed institutional logic implying a change towards individual responsibility for disease. Policy makers ought to consider complexities of logic in order to tailor the different needs of users.     

The implementation of a global fund grant in Lesotho: applying a framework on knowledge absorptive capacity

One of the biggest challenges in scaling up health interventions in sub-Saharan Africa for government recipients is to effectively manage the rapid influx of aid from different donors, each with its own requirements and conditions. However, there is little empirical evidence on how governments absorb knowledge from new donors in order to satisfy their requirements. This case study applies Cuellar and Gallivan's (2006) framework on knowledge absorptive capacity (AC) to illustrate how recipient government organisations in Lesotho identified, assimilated and utilised knowledge on how to meet the disbursement and reporting requirements of Lesotho's Round 5 grant from the Global Fund to Fight AIDS, TB and Malaria (Global Fund). In-depth topic guided interviews with 22 respondents and document reviews were conducted between July 2008 and February 2009. Analysis focused on six organisational determinants that affect an organisation's absorptive capacity: prior-related knowledge, combinative capabilities, motivation, organisational structure, cultural match, and communication channels. Absorptive capacity was mostly evident at the level of the Principal Recipient, the Ministry of Finance, who established a new organisational unit to meet the requirements of Global Fund Grants, while the level of AC was less advanced among the Ministry of Health (Sub-Recipient) and district level implementers. Recipient organisations can increase their absorptive capacity, not only through prior knowledge of donor requirements, but also by deliberately changing their organisational form and through combinative capabilities. The study also revealed how vulnerable African governments are to loss of staff capacity. The application of organisational theory to analyse the interactions of donor agencies with public and non-public country stakeholders illustrates the complexity of the environment that aid recipient governments have to manage.     

Communicating about pupils in mainstream school with special health needs: the NHS perspective

AIM: To add to previous research carried out with young people, parents and teachers, by investigating health staff's perspectives on the difficulties, and possibilities for, achieving good communication with school staff with regard to children in mainstream school with a chronic illness or physical disability. RESEARCH DESIGN AND METHODS: A qualitative research study was carried out in one NHS Trust. Twenty semi-structured interviews were carried out with a purposive sample of health staff to cover the spectrum of professionals who have responsibility for meeting the needs of children with a chronic illness or physical disability in mainstream schools (paediatricians, school doctors, school nurses, specialist nurses, health visitors, GPs, speech and language therapists, paediatric occupational therapists, paediatric physiotherapists, clinical psychologists and psychiatrists). RESULTS: The extent to which health professionals communicated with school staff, and the way in which they went about it, varied widely. Communication was facilitated by joint meetings, shared documentation, and local policy development. Sources of difficulty in communication between health and education staff were: the parent as a conduit of information; the practical difficulties of arranging meetings; and lack of knowledge about other professionals' roles. The ethos of the school with regard to health matters, and the flow of information within health services, also had an impact on the communication process. Participants' recommendations focused on two key issues: clarification of the roles of health and education staff with regard to this group of pupils; and how information should flow from health to school staff. DISCUSSION: Many of the findings parallel the previous research with teachers, indicating agreement between professionals from different agencies about aspects of the communication process which are problematic and require attention. The findings suggest that improving communication requires both joint work between health and education staff, and improvements to practice within each agency.     

Exploring the use of economic evidence to inform investment in disease prevention – a qualitative study

Objective : In the context of growing financial pressures on health budgets, cost‐effective prevention strategies are needed to address the burden from non‐communicable disease in Australia. We explored how decision makers use economic evidence to inform such investment and how such evidence generated can more effectively meet the needs of end users. Methods : Thematic analysis of in‐depth interviews with 15 high level stakeholders (Treasury, state health departments and the insurance industry), supplemented by documentary analysis. Results : Types of prevention approaches and economic evidence relevant to decision makers differed by organisational perspective. Capacity building in understanding economic evaluations and research evidence that addresses the differing criteria for investment used by different organisations is needed. The task of determining investment priorities in disease prevention comes with significant challenges including ideological barriers, delayed outcome measures, and implementation uncertainties. Conclusions and Implications for public health : Promoting the greater use of economic evidence in prevention requires more work on two fronts: tailoring the methods used by economists to better match the organisational imperatives of end users; and promoting greater consideration of broader societal and health sector perspectives among end users. This will require significant infrastructure development, monitoring and evaluation, stronger national leadership and a greater emphasis on evidence coproduction.     

Everyday life with AIDS/HIV: surveys in the social sciences

Research on persons infected with HIV is critically assessed by using the notions developed in the sociology of illness. Has this research stimulated new questions or led to reformulations in research paradigms? Methodological problems related to data collection are pointed out, namely: the recruitment of HIV-positive participants for such studies and the stance they adopt during interviews. The contributions made by studies that have focused on adjustment strategies or resorted to the notions of stigmatization, identity and illness trajectory are also discussed. In conclusion, questions are raised about what implications the new HIV/AIDS treatments will have on this field of social science research.     

Beyond community-based diabetes management and the COAG coordinated care trial

Objective: This article describes the patient management processes developed during the Council of Australian Governments (COAG) coordinated care trial and use of health outcome measures to monitor changes in utilisation patterns and patient well‐being over time for a subgroup of 398 patients with type 2 diabetes. Design: The Eyre component of the South Australian (SA) HealthPlus coordinated care trial was a matched geographically controlled study in which the outcomes for the intervention group of 1350 patients were compared with those of a similar control group of 500 patients in another rural health region in SA. Setting: The trial was carried out on Eyre Peninsula in SA across populations in rural communities and in the main centres of Whyalla, Port Lincoln and Ceduna. Care planning was organised through general practitioner practices and services negotiated with allied health services and hospitals to meet patient needs. Subjects: The SA HealthPlus trial included 1350 patients with chronic and complex illness. A subset of this group comprising 398 patients with type 2 diabetes is described in this report. Patients recruited into the three‐year trial were care planned using a patient centred care planning model through which patient goals were generated along with medical management goals developed by clinicians and primary health care professionals. Relevant health services were scheduled in line with best practice and care plans were reviewed each year. Patient service utilisation, progress towards achieving health related goals and patient health outcomes were recorded and assessed to determine improvements in health and well‐being along with the cost and profile of the services provided. Results: Significant numbers of patients experienced improved health outcomes as a consequence of their involvement in the trial, and utilisation data showed reductions in hospital and medical expenditure for some patients. These results suggest that methods applied in the SA HealthPlus coordinated care trial have led to improvements in health outcomes for patients with diabetes and other chronic illnesses. In addition, the processes associated with the COAG trial motivated significant organisational change in the Regional Health Service as well as providing an opportunity to study the health and well‐being outcomes resulting from a major community health intervention. Conclusions: The importance of the SA HealthPlus trial has been the demonstrated link between a formal research trial and significant developments in the larger health system with the trial not only leading to improvements in clinical outcomes for patients, but also acting as a catalyst for organisational reform. We now need to look beyond the illness focus of health outcome research to develop population based health approaches to improving overall community well‐being. What is already known: Much work has been completed in recent years tracing the clinical impact of more effective management of patients with chronic illness. Evidence suggests that more structured management of patient care and better access resources and support can improve patient well‐being and reduce demand on acute care services. What is needed, however, are mechanisms for managing patients to access relevant care and to comply with best practice protocols. Lowered HbA1c readings correlate with reduced crises for diabetic patients, but how can we encourage patients to engage in practices that actually lower these levels? What this study adds: The current study, based on work carried out during the COAG coordinated care trials, suggests that a structured patient centred care planning process can improve patient knowledge of their condition and increase motivation for sustainable behaviour change in the way they manage their illness. These processes of patient engagement and symptom monitoring have led to better long‐term health and well‐being for patients with diabetes. The wider application of such processes of care management will be an important next step in improving the management of health and well‐being at larger population levels.