The governance of pluralist health care systems: An initial review and typology.

We here argue that study of governance systems within increasingly pluralist health care systems needs to be broadened beyond traditionally public sector orientated literature. We develop an initial typology of multiple governance systems within the English health care sector and derive exploratory questions to inform future empirical investigation. We add to existing literature by considering the coexistence of - and possible tensions between - multiple governance systems in a pluralised health and social care system.

Are inspectors' assessments reliable? Ratings of NHS acute hospital trust services in England.

The credibility of a regulator could be threatened if stakeholders perceive that assessments of performance made by its inspectors are unreliable. Yet there is little published research on the reliability of inspectors' assessments of health care organizations' services. Objectives We investigated the inter-rater reliability of assessments made by inspectors inspecting acute hospitals in England during the piloting of a new regulatory model implemented by the Care Quality Commission (CQC) during 2013 and 2014. Multi-professional teams of inspectors rated service provision on a four-point scale for each of five domains: safety; effectiveness; caring; responsiveness; and leadership. Methods In an online survey, we asked individual inspectors to assign a domain and a rating to each of 10 vignettes of service information extracted from CQC inspection reports. We used these data to simulate the ratings that might be produced by teams of inspectors. We also observed inspection teams in action, and interviewed inspectors and staff from hospitals that had been inspected. Results Levels of agreement varied substantially from vignette to vignette. Characteristics such as professional background explained only a very small part of the variation. Overall, agreement was higher on ratings than on domains, and for groups of inspectors compared with individual inspectors. A number of potential causes of disagreement were identified, such as differences regarding the weight that should be given to contextual factors and general uncertainty about interpreting the rating and domain categories. Conclusion Groups of inspectors produced more reliable assessments than individual inspectors, and there is evidence to support the utility of appropriate discussions between inspectors in improving reliability. The reliability of domain allocations was lower than for ratings. It is important to define categories and rating levels clearly, and to train inspectors in their use. Further research is needed to replicate these results now that the model has been fully implemented, and to understand better the impact that inspector uncertainty and disagreement may have on published CQC ratings.

Challenges of commissioning and contracting for integrated care in the National Health Service (NHS) in England.

For many years there has been a separation between purchasing and provision of services in the English National Health Service (NHS). Many studies report that this commissioning function has been weak: purchasers have had little impact or power in negotiations with large acute providers, and have had limited strategic control over the delivery of care. Nevertheless, commissioning has become increasingly embedded in the NHS structure since the arrival of Clinical Commissioning Groups (CCGs) in 2012. Recently, some of these CCGs have focused on how they can contract and commission in different ways to stimulate greater collaboration across providers. This paper examines experiences of commissioning and contracting for integrated care in the English NHS, based on a series of national-level interviews and case studies of five health economies that are implementing novel contracting models. The cases illustrated here demonstrate early experiments to drive innovation through contracting in the NHS that have largely relied on the vision of individual teams or leaders, in combination with external legal, procurement and actuarial support. It is unlikely that this approach will be sustainable or replicable across the country or internationally, despite the best intentions of commissioners. Designing and operating novel contractual approaches will require considerable determination, alongside advanced skills in procurement, contract management and commissioning. The cost of developing new contractual approaches is high, and as the process is difficult and resource-intensive, it is likely that dedicated teams or programs will be required to drive significant improvement.

Evaluating a complex system-wide intervention using the difference in differences method: the Delivering Choice Programme.

OBJECTIVES: We report the use of difference in differences (DiD) methodology to evaluate a complex, system-wide healthcare intervention. We use the worked example of evaluating the Marie Curie Delivering Choice Programme (DCP) for advanced illness in a large urban healthcare economy. METHODS: DiD was selected because a randomised controlled trial was not feasible. The method allows for before and after comparison of changes that occur in an intervention site with a matched control site. This enables analysts to control for the effect of the intervention in the absence of a local control. Any policy, seasonal or other confounding effects over the test period are assumed to have occurred in a balanced way at both sites. Data were obtained from primary care trusts. Outcomes were place of death, inpatient admissions, length of stay and costs. RESULTS: Small changes were identified between pre- and post-DCP outputs in the intervention site. The proportion of home deaths and median cost increased slightly, while the number of admissions per patient and the average length of stay per admission decreased slightly. None of these changes was statistically significant. CONCLUSIONS: Effects estimates were limited by small numbers accessing new services and selection bias in sample population and comparator site. In evaluating the effect of a complex healthcare intervention, the choice of analysis method and output measures is crucial. Alternatives to randomised controlled trials may be required for evaluating large scale complex interventions and the DiD approach is suitable, subject to careful selection of measured outputs and control population.

How "accountable" are accountable care organizations?

BACKGROUND: The establishment of accountable care organizations (ACOs) in the Affordable Care Act (ACA) was intended to support both cost savings and high-quality care. However, a key challenge will be to ensure that governance and accountability mechanisms are sufficient to support those twin ambitions. PURPOSE: This exploratory study considers how recently developed ACOs have established governance structures and accountability mechanisms, particularly focusing on attempts at collaborative accountability and shared governance arrangements. METHODOLOGY: Four case studies of ACOs across the United States were undertaken, with data collected throughout 2012. These involved 34 semistructured interviews with ACO administrative and clinical leaders, observation of nine meetings, and a review of documentary materials from each ACO. FINDINGS: We identified very few examples of physicians being held to account as a collective and therefore only limited evidence of collaborative accountability impacting on behavior change. However, ACO leaders do have many mechanisms available to stimulate change across physicians. The challenge is to determine governance structure(s) and accountability mechanisms that facilitate the most effective combination of approaches, measures, incentives, and sanctions to achieve the goals of more accountable care. PRACTICE IMPLICATIONS: Accountability structures and processes will need to be tailored to local membership composition, historical evolution, and current stage of development. There are also some common lessons to be drawn. Shared goals and incentives should be reflected through performance criteria. It is important to align measures and thresholds across payers to ensure ACOs are not unnecessarily burdened or compromised by reporting on different and potentially disjointed measures. Finally, emphasis needs to be placed on the importance of credible, transparent data. This exploratory study provides early evidence regarding how ACOs are establishing their governance and accountability arrangements and provides a foundation for future research and theory-building in this area.

Delivering better end-of-life care in England: barriers to access for patients with a non-cancer diagnosis.

The End of Life Care Strategy (Department of Health, 2008) radically raised the profile of end-of-life care in England, signalling the need for development in planning and delivery, to ensure that individuals are able to exercise genuine choice in how and where they are cared for and die. Research has indicated that there have been continuing difficulties in access to high-quality and appropriate support at the end of life, particularly for patients with a diagnosis other than cancer. This article uses research findings from three case studies of end-of-life care delivery in England to highlight some of the barriers that continue to exist, and understand these challenges in more depth. Access to high-quality and appropriate end-of-life care has been a challenge for all patients nearing the end of life. However, the findings from this research indicate that there are several interrelated reasons why access to end-of-life care services can be more difficult for patients with a non-cancer diagnosis. These issues relate to differences in disease trajectories and subsequent care planning, which are further entrenched by existing funding arrangements.

Supporting care home residents at the end of life.

The English Department of Health's 2008 End of Life Care Strategy reported that 17% of deaths in England occur in care homes, with the majority of these in the 85 years and over age group. Given this, the ageing population, and the projected increase in the number of people dying, it is evident that the number of deaths in care homes is likely to increase. The research presented here seeks to consider the factors that support residents to remain in care homes towards the end of life. This study is based on four case studies of care homes in England and on interviews with external health and social care professionals who interact with these care homes. The findings indicate that three core features are fundamental to the delivery of high-quality end-of-life care in care homes: advance care planning, multidisciplinary communication and working, and provision of dignified and compassionate care. Previous research has uncovered some of these issues; this study suggests that it is the combination of these factors that makes them fundamental to meeting residents' care preferences and ensuring high-quality care.

Should diabetes be commissioned through multidisciplinary networks, rather than Practice Based Commissioning?

AIMS: Diabetes is recognized as a complex, long term, largely asymptomatic condition requiring self management skills, a range of health care professionals and articulated health services. Diabetes Networks have been introduced to provide guidance from people with diabetes and local health professionals with different skills to ensure that diabetes care is well organized, sustainable and delivers quality care. We have considered the role of Diabetes Networks in the English setting. METHODS: Drawing on studies of health service organization and health policy, we describe the context in which diabetes commissioning is currently occurring in England, the role of Diabetes Networks and key components for an effective Diabetes Network. RESULTS: We have identified that Diabetes Networks are not currently mandatory and discovered policy approaches that are likely to work against safe, timely, integrated approaches to diabetes services with potentially harmful impacts on people with diabetes in the future. Practice Based Commissioning, where it sidelines Diabetes Networks, is a particular concern. We have identified key components of Diabetes Networks including explicit frameworks for leadership, membership, funding, decision making, communication and action. CONCLUSIONS: Diabetes is a condition requiring collaboration between all involved. Diabetes Networks include patients and all relevant health professionals and should dictate what and how diabetes care should be commissioned within the local health economy.

Evaluation of a pilot study day for healthcare assistants and social care officers.

UNLABELLED: This report evaluates a pilot study day, which provided an introduction for healthcare assistants and social care officers into the causes, incidence and impact of symptoms encountered when providing palliative care for people with advanced disease. AIM: To demonstrate whether the study day facilitated an increase in confidence and knowledge in key areas of symptom control, the degree of satisfaction with the study day and whether participants were able to use information from the study day in practice. METHOD: Both qualitative and quantitative methods were employed in the evaluation process. Data were collected using satisfaction questionnaires, pre- and post-test questionnaires, and a telephone follow-up for self-selected participants. RESULTS: There was a high degree of satisfaction with the study day. The results demonstrated statistically significant increases in both knowledge and confidence in helping to manage key symptoms encountered in palliative care patients. CONCLUSION: All participants reported that the aims of the day were met and agreed that the topics were relevant to practice.

Centralisation of end of life care coordination: impact on the role of community providers.

Background The recently published End of Life Care Strategy (1) and emerging service improvements have raised the profile of end of life care (EOLC) across health and social care sectors. Policy emphasises providing patients with more choice over where they are cared for at the end of life. Surveys and anecdotal evidence suggest that the majority of people would prefer to be cared for (and die) in their own home. Such care provision evidently requires considered planning across community providers. Some areas have instigated a centralised administrative process for such care planning. Setting This shift towards centralising the administrative function of care coordination for patients who are nearing the end of life has implications for community care providers. Question This paper seeks to understand the impact that centralising EOLC care coordination in the community has had on community providers. Methods This paper draws on findings from case studies of two large primary care trust (PCT) regions in England. One hundred and two semi-structured interviews with service managers, commissioners and providers were conducted across the two case studies, as well as two focus groups (ten participants - acute and community nurses), observation of key local palliative care planning meetings, and documentary analysis of strategic and operational papers. Results The findings presented demonstrate that a centralised approach to care planning has positive outcomes for community nurses, who are able to spend more time delivering direct patient care. However, there were challenges associated with the approach - particularly the capacity of an administrative process to intelligently allocate finite resources amongst patients with a range of care needs. Conclusions The centralisation of care planning had implications for how community nurses conceptualised their role in the delivery and coordination of EOLC. Community nurses were positive regarding the alleviation of the administrative burden; however the approach challenged their professional role as key worker - particularly in making judgements as to the nature and appropriateness of patient care packages.

Models of governance and the changing role of the board in the "modernised" UK health sector.

PURPOSE: The aim of this paper is to show that there has been an increasing focus on networks as a model of service delivery and governance in the UK public sector. As an early example, managed clinical networks for cancer were initially considered to represent an ideological move towards a softer model of governance, with an emphasis on moving across the vertical lines that were strengthened or established during the new public management (NPM) movement of the 1990s. The NPM ideology of the 1990s emphasised the role of Boards and powerful non-executives in governing public services. This paper seeks to explore the role of the Board in the UK health sector under the apparent emerging "post-NPM" ideological framework of accountability. DESIGN/METHODOLOGY/APPROACH: The paper is based on findings from five comparative case studies of managed clinical networks for cancer in London. FINDINGS: The paper finds that cancer network boards have had limited strategic influence as these networks are constrained by a continued emphasis of centralised performance management and structural reconfiguration, which become dominant during the NPM era. PRACTICAL IMPLICATIONS: The inability of the post-NPM governance ideology to make a significant impact in the UK, and the resulting confused and conflictual framework, have hindered the initial intention of cancer networks as a forum for spreading best practice across organisational boundaries. ORIGINALITY/VALUE: There is only limited research on the emergent remit, structure or strategy of public sector Boards in the UK, and very limited research on the role of Boards in health care networks: the paper provides some illumination on this limited area of study.