Is digital health care more equitable? The framing of health inequalities within England's digital health policy 2010–2017

Informed by a discourse analysis, this article examines the framing of equity within the UK's digital health policies between 2010 and 2017, focusing on England's development of NHS Digital and its situation within the UK Government's wider digital strategy. Analysis of significant policy documents reveals three interrelated discourses that are engaged within England's digital health policies: equity as a neoliberal imaginary of digital efficiency and empowerment; digital health as a pathway towards democratising health care through data‐sharing, co‐creation and collaboration; and finally, digital health as a route towards extending citizen autonomy through their access to data systems. It advances knowledge of the relationship between digital health policy and health inequalities. Revealing that while inclusion remains a priority area for policymakers, equity is being constituted in ways that reflect broader discourses of neoliberalism, empowerment and the turn to the market for technological solutionism, which may potentially exacerbate health inequalities.     

Perspectives on clinical leadership: a qualitative study exploring the views of senior healthcare leaders in the UK

Introduction

Clinicians are being asked to play a major role leading the NHS. While much is written on about clinical leadership, little research in the medical literature has examined perceptions of the term or mapped the perceived attributes required for success.

Objective

To capture the views of senior UK healthcare leaders regarding their perception of the term `clinical leadership'' and the cultural backdrop in which it is being espoused.

Setting

UK Healthcare sector

Participants

Senior UK Healthcare leaders

Methods

Twenty senior healthcare leaders including a former Health Minister, NHS Executives, NHS Strategic Health Authority, PCT and Acute Trust chief executives and medical directors, Medical Deans and other key actors in the UK medical leadership arena were interviewed between 2010 and 2011 using a semi-structured interview technique. Using grounded theory, themes were identified and subsequently analysed in an attempt to answer the broad questions posed.

Main outcome measures

Not applicable for a qualitative research project

Results

A number of themes emerged from this qualitative study. First, there was evidence of changing attitudes among doctors, particularly trainees, towards becoming involved in clinical leadership. However, there was unease over the ambiguity of the term ‘clinical leadership’ and the implications for the future. There was, however, broad agreement as to the perceived attributes and skills required for success in healthcare leadership.

Conclusions

Clinical leadership is often perceived to be doctor centric and ‘Healthcare Leadership’ may be a more inclusive term. An understanding of the historical medico-political context of the leadership debate is required by all healthcare leaders to fully understand the challenges of changing healthcare culture. Whilst the broad attributes deemed essential for success as a healthcare leaders are not new, significant effort and investment, including a physical Healthcare Academy, are required to best utilise and harmonise the breadth of leadership talent in the NHS.     

'Wading through treacle': quality improvement lessons from the frontline

In a time of financial uncertainty and structural reform, the National Health Service (NHS) in England needs clinical leadership to help improve the quality of patient care. Increasingly, leadership development is being targeted at doctors in postgraduate training to help prepare them for their future leadership roles as consultants and general practitioners. However, there is a risk that we are missing an opportunity here by failing to recognise the role that doctors in training can play now, during their training. As our frontline clinicians they have a unique view of the health service and the inefficiencies therein. The London Deanery has been running an educational programme called Beyond Audit to provide doctors in training with quality improvement skills. During this programme we have been given a unique insight into NHS systems as viewed by junior doctors. They have identified a wide range of small system problems that, when combined, result in large-scale inefficiency and prevent the delivery of high quality patient care. These problems they identify have implications for cost, efficiency, patient safety, team-working and patient experience. Any attempt to improve the quality of care delivered in the NHS needs to look at the system from the point of view of those delivering the care, including our doctors in postgraduate training. By empowering them to make improvements to the systems that they see, there is the potential to make significant improvement in the quality of patient care that they deliver.     

NHS Direct: managing demand for primary care?

This paper considers how NHS Direct is affecting demand for primary care in particular out‐of‐hours services from GPs. This is reviewed through a 3‐year study of NHS Direct and HARMONI, the integrated telephone health helpline based in West London. It describes the policy background and development of the services on the site, and some of the outcomes of the HARMONI commissioned research to answer the question ‘Has NHS Direct increased the workload for HARMONI doctors?’. The research adopted both a qualitative and quantitative approach using cross‐sectional and longitudinal analysis of the data collected. The analysis of the data reveals the issues as both complex and dynamic in nature. The research shows that while there has been no significant change to the total volume of activity, changes within patient groups notably the elderly and children, and in individual GP practices may be significant. In addition, the changes in organizational arrangements may influence significant changes in referral patterns such as GP out‐of‐hours visits. This was confirmed in the interview data indicating a link between the change in nurses' role from gatekeeper to patient advocate, which happened when they ceased to be employees of the part‐time co‐op and began to work instead for the 24 hours, 7 days a week NHS Direct service. The conclusions drawn are that behavioural and organizational changes are at least as significant as the evidence‐based computerized decision support software in changing the demand for primary care. Further evidence cited is that a different demand pattern of calls was experienced by those local GPs not integrated into out‐of‐hours provision at NHS Direct West London at the time of the study. Copyright © 2004 John Wiley & Sons, Ltd.     

Leadership development in health care: a word of caution

Leadership development is seen as central to the modernisation agenda of the NHS. It has been identified in key policy documents and a range of leadership development programmes have been developed to meet this need This paper reviews the evidence concerning leadership development in nursing. The conclusion reached is that leadership is only one element in the changes that need to occur in health care. Too much emphasis on leadership without an equal concern for transforming the organisations nurses and other health personnel work in may result in leadership being added to the list of transient management "fads" which have characterised health care in recent years.     

Efficiency in the National Health Service: lessons from abroad.

Although the NHS gives relatively good value for money when compared to other countries' health care systems, there are managerial initiatives from abroad that could potentially increase NHS efficiency. However, there is currently very little systematic evaluation of the impact of managerial interventions in terms of their benefits and costs. This paper considers four areas of current policy interest (evaluation of new medical technologies, quality assurance, primary health care and the public/private mix), reviews experience abroad and outlines how promising initiatives could be evaluated in the NHS setting. It is argued that if lessons are to be learned about the efficient management of the NHS from abroad or not, there needs to be more systematic evaluation of managerial interventions along the lines commonly proposed for clinical interventions.     

A critical account of the rise and spread of 'leadership': the case of U.K. healthcare

This paper considers the rise of 'leadership' in discourses relating to the British health service, and the application of the term to increasingly heterogeneous actors. Analysing interviews with NHS chief executives from the late 1990s, and key policy documents published since, we highlight how leadership has become a term of choice among policymakers, with positive cultural valences which previously predominant terms such as 'management' now lack. We note in particular how leadership is increasingly conferred not only on those in positions of formal power but on frontline clinicians, patients and even the public, and how not just the implementation but the design of policy is now constructed as being led by these groups. Such constructions of the distribution of power in the health service, however, contradict the picture drawn by academic work. We suggest, therefore, that part of the purpose of leadership discourse is to align the subjectivities of health-service stakeholders with policy intentions, making their implementation not just everyone's responsibility, but part of everyone's sense of self. Given the realities of organizational life for many of the subjects of leadership discourse, however, the extent to which leadership retains its current positive associations and ubiquity remains to be seen.     

Equipping clinical leaders for system and service improvements in quality and safety: an Australian experience

Objective : To develop clinical leadership among health professionals working in public sector organisations to improve their skills in ensuring high quality and safe health services. Methods : A longitudinal pre‐post‐intervention mixed methods study that included 60 health professionals working in one state in Australia. Results : The program was successful in the development of clinical leaders. Conclusions : An interdisciplinary, inter‐sectoral leadership development program involving health professionals from metropolitan, regional and rural areas can be successful in developing knowledge, skills and competencies among these health professionals in health service quality and safety. Implications : Health professionals can participate in a development program to enhance their clinical leadership skills. While this was a post‐qualification course, targeting experienced health professionals, the learnings could be applied to pre‐qualification education of health professionals.     

Clinical leadership: the elephant in the room

The article explores the concept of clinical leadership in the National Health Service in the UK by seeking to establish a workable definition and by contrasting it with managerial leadership, focussing on the 'disconnected hierarchy' in professional organizations. It proposes that the problems faced by clinical leadership relate to the current nature of general management in the NHS and concludes by suggesting that clinical leadership is the 'elephant in the room'-often ignored or unaddressed.     

Systemization of leadership for the systemization health care of health care: the unaddressed issue in health care reform

The case literature strongly suggests that both in England and in Australia health care reforms have had very little impact in terms of "improved performance". It is in the context of a perceived failure in the implementation of the reforms that an interest has arisen in leadership at the level of individual clinical units (e.g an orthopaedics unit or birth unit), as the possible "fix" for bridging the promise-performance gap. Drawing upon extensive case studies that highlight the problem and context for appropriate forms of leadership, this paper argues that the appropriate discourse, in terms of leadership in health reform, needs to focus upon the issue of authorization. In making this argument, addresses the current conceptions of leadership that have been advanced in the discourse before offering some case study material that is suggestive of why attention should be focused on the issue of authorization. Illustrates how and why the processes of leading, central to implementing reform, cannot be construed as socially disembodied processes. Rather, leading and following are partial and partisan processes whose potential is circumscribed by participants' position-takings and what is authorized in the institutional settings in which they are located Argues that the "following" that clinical unit managers could command was shaped by the sub-cultures and "regulatory ideals" with which staff of each profession are involved In the interests of reform, policy players in health should not be focusing attention solely upon the performative qualities and potential leadership abilities of middle level management, but also on their own performance. They should consider how their actions affect what is authorized institutionally and which sets the scope and limits of the leadership-followership dialectic in clinical settings.     

Health and efficiency: Clinical effectiveness dissected

If the exclusive promotion of values inimical to our basic humanity extends to the health care policy arena, we face a defensive, restricted, impersonal and ultimately impoverished health care system. Americans know it already as ‘managed-care’. This is why it is crucial for health policy analysts to make explicit the role of values in policy-making, especially that involving the input of ‘value-neutral’ economics. The nature of any clinical effectiveness policy will be determined by the understanding of cost-effectiveness employed in its design and implementation. Given that cost-effectiveness is nowadays usually defined according to health economists’ criteria, the battle over the meaning of clinical effectiveness is a significant development in health economics’ move to assume control of the NHS.     

More patient choice in England's national health service.

A new political consensus has emerged over the benefits of new rights for patients to choose their provider of elective health care in the English National Health Service. From December 2005, patients will be able to select from a number of alternative providers at the time they are referred for treatment. In the longer term, patients will be able to access care at any public or private provider that meets national quality and cost standards. The government intends that this policy will lead to improvements in the quality and efficiency of health care and will reduce levels of inequity among patients. Pilot schemes have shown that a majority of patients will exercise a choice of provider when this is offered. However, the policy of patient choice may involve significant costs to the NHS and may be more difficult to implement outside urban areas. Further, the information needed to support patients' choices is not yet available. Whether such a policy will increase or decrease levels of equity in the English NHS remains open to debate.     

Exploring the human resource implications of clinical governance

In 1998, clinical governance was introduced in the National Health Service, UK (NHS) as a major policy initiative to improve the quality of clinical care. The implementation of clinical governance is crucially dependent on the skills, competencies and willingness of the NHS staff. In turn, clinical governance influences the way people work in health care organisations. Therefore, it is no surprise that the introduction of clinical governance has thrown-up new challenges for human resource management. However, what are these human resource management challenges under the clinical governance framework? The current literature on the subject provides no answer. This article attempts to fill this gap in the literature. A qualitative approach influenced by phenomenological case study approach has been adopted. A heterogeneous group of 33 persons identified through a purposive sampling procedure were interviewed using a semi-structured format. The results indicate that the staff members appreciate the crucial role of human resources management in the implementation of clinical governance. However, there is little evidence to suggest that senior management is paying attention to develop the human resources function around the clinical governance agenda. The seven major human resource implications of clinical governance that emerged from the data analysis are discussed. The author argues that a more proactive HR approach is needed to make clinical governance everyone's business in the NHS organisations.     

Trust relations in health care: developing a theoretical framework for the "new" NHS

PURPOSE: This paper seeks to address how and why trust relations in the NHS may be changing and presents a theoretical framework for exploring them in future empirical research. DESIGN/METHODOLOGY/APPROACH: This paper provides a conceptual analysis. It proposes that public and patient trust in health care in the U.K. appears to be shaped by a variety of factors. From a macro perspective, any changes in levels of public trust in health care institutions appear to derive partly from top-down policy initiatives that have altered the way in which health services are organised and partly from broader social and cultural processes. A variety of policy initiatives, including the introduction of clinical governance and the resulting use of performance management to scrutinise and change clinical activity, increasing patient choice and involvement in decision-making regarding their care, are examined for how they have changed the context for trust relations within the NHS. FINDINGS: It is argued that these policy initiatives have produced a new context for trust relations within the NHS, shifting the inter-dependence and distribution of power between patients, clinicians, and mangers and changing their vulnerability to each other and to health care institutions. The paper presents a theoretical framework based on current policy discourses which illustrates how new forms of trust relations may be emerging in this new context of health care delivery, reflecting a change in motivations for trust from affect based to cognition based trust as patients, clinicians and managers become more active partners in trust relations. The framework suggests that trust relations in all three types of relationship in the "new" modernised NHS might, in general, be particularly characterised by an emphasis on communication, providing information and the use of "evidence" to support decisions in a reciprocal, negotiated alliance. ORIGINALITY/VALUE: The paper examines the drivers for change in trust in health care relations in the U.K. and develops a theoretical framework for the emergence of new trust relations that can be subsequently explored through empirical research.     

Competition policy for health care provision in Norway

Competition policy has played a very limited role for health care provision in Norway. The main reason is that Norway has a National Health Service (NHS) with extensive public provision and a wide set of sector-specific regulations that limit the scope for competition. However, the last two decades, several reforms have deregulated health care provision and opened up for provider competition along some dimensions. For specialised care, the government has introduced patient choice and (partly) activity (DRG) based funding, but also corporatised public hospitals and allowed for more private provision. For primary care, a reform changed the payment scheme to capitation and (a higher share of) fee-for-service, inducing almost all GPs on fixed salary contracts to become self-employed. While these reforms have the potential for generating competition in the Norwegian NHS, the empirical evidence is quite limited and the findings are mixed. We identify a set of possible caveats that may weaken the incentives for provider competition – such as the partial implementation of DRG pricing, the dual purchaser–provider role of regional health authorities, and the extensive consolidation of public hospitals – and argue that there is great scope for competition policy measures that could stimulate provider competition within the Norwegian NHS.     

Using economic evidence to support decision making: a case study of assertive community treatment within the UK National Service Framework for Mental Health

This study illustrates a process of accessing and utilising clinical and economic evidence in health care decision making. The scenario examined was that of a UK Health Authority evaluating evidence prior to the introduction of assertive community treatment (ACT), as part of guidance from the UK National Service Framework for Mental Health. The consistency between clinical and cost evidence from a number of sources (Cochrane Database of Systematic Reviews (CDSR), Database of Reviews of Effectiveness (DARE), HTA database, NHS Economic Evaluation database (NHS EED)) was also addressed, as was the usefulness of structured abstracts on NHS EED. The findings showed that within specified caveats ACT tends to be more effective and also less costly than alternative interventions; there is general agreement between sources principally reporting effectiveness and economic evaluations; and NHS EED abstracts are useful in the decision making process where information gaps exist. In terms of health care policy in the health authority examined, two ACT teams were subsequently introduced in the city of Leicester. Although systematic reviews and appraisals of evidence are arguably the gold standard in health care decision making, the study illustrates how the use of databases of structured abstracts can assist in making optimal choices in real life decision making scenarios.     

Constructing notions of healthcare productivity: the call for a new professionalism?

Improving performance is an imperative for most healthcare systems in industrialised countries. This article considers one such system, the UK's National Health Service (NHS). Recent NHS reforms and strategies have advocated improved healthcare productivity as a fundamental objective of policy and professional work. This article explores the construction of productivity in contemporary NHS discourse, analysing it via the Foucauldian concept of governmentality. In this manner it is possible to investigate claims that the commodification of health work constitutes a threat to autonomy, and counter that with an alternative view from a perspective of neoliberal self‐governance. Contemporary policy documents pertaining to NHS productivity were analysed using discourse analysis to examine the way in which productivity was framed and how responsibility for inefficient resource use, and possible solutions, were constructed. Data reveals the notion of productivity as problematic, with professionals as key protagonists. A common narrative identifies traditional NHS command/control principles as having failed to engage professionals or having been actively obstructed by them. In contrast, new productivity narratives are framed as direct appeals to professionalism. These new narratives do not support deprofessionalisation, but rather reconstruct responsibilities, what might be called ‘new professionalism’, in which productivity is identified as an individualised professional duty.     

Research into purchasing health care: time to face the challenge.

Purchasing health care is at the core of the reforms of the UK NHS and yet there is little research evidence on which the policy is based. Research in this area is hampered by a lack of clarity over the aims of purchasing and the pace of change within the NHS. Purchasing developments such as general practice fund-holding are proceeding without a large scale evaluation of their impact. At a national level a research effort is required to investigate this key area of the NHS reforms.