Investigating the governance of autonomous public hospitals in England: multi-site case study of NHS foundation trusts.

OBJECTIVE: To investigate the external and internal governance of NHS foundation trusts (FTs), which have increased autonomy, and local members and governors unlike other NHS trusts. METHODS: In depth, three-year case studies of four FTs; and analysis of national quantitative data on all FT hospitals and NHS Trust hospitals to give national context. Data included 111 interviews with managers, clinicians, governors and members, and local purchasers; observation of meetings; and analysis of FTs' documents. RESULTS: The four case study FTs were similar to other FTs. They had used their increased autonomy to develop more business-like practices. The FT regulator, Monitor, intervened only when there were reported problems in FT performance. National targets applying to the NHS also had a large effect on FT behaviour. FTs saw themselves as part of the local health economy and tried to maintain good relationships with local organisations. Relationships between governors and the FTs' executives were still developing, and not all governors felt able to hold their FT to account. The skills and experience of staff members and governors were under-used in the new governance structures. CONCLUSIONS: It is easier to increase autonomy for public hospitals than to increase local accountability. Hospital managers are likely to be interested in making decisions with less central government control, whilst mechanisms for local accountability are notoriously difficult to design and operate. Further consideration of internal governance of FTs is needed. In a deteriorating financial climate, FTs should be better placed to make savings, due to their more business-like practices.

Why does nursing workload spike every ten years?

Trends in nursing workload can be analysed by capturing and counting workload data across time.

Older people in transition from illness to health: trajectories of recovery.

Despite growing interest in the meaning of illness and recovery in older age, much of the research has focused on particular conditions, such as stroke; yet, illness in later life is considerably more diverse. In this article, we examine the experience of illness and process of recovery through interviews with 64 older people receiving intermediate care, a form of transitional care to support people between illness and resumption of everyday life routines. They describe four recovery trajectories generated from individuals' accounts of illness and their perspective on recovery: cure and restoration, adjusting to discontinuity and establishing markers of continuity, getting back and keeping going, and managing uncertainty. We conclude that several interacting factors shape the meaning of illness and the process of recovery in later life: prior circumstances, illness onset and trajectory, comorbid health problems, and cumulative loss in advanced older age.

Networks and governance: the case of intermediate care.

The present paper describes a novel approach to the study of services conceptualised as networks. It uses data collected as part of a case study evaluation of intermediate care, a 'joined-up government' policy that was explicitly intended to dissolve the boundaries between health and social care services. The evaluation was undertaken in five localities in England. Routine service use data were collated and standardised for the 12-month period from November 2002 to October 2003. A cohort of 258 service users was recruited during a census month (June 2003), and more detailed data on their personal characteristics and experiences prior to and during their intermediate care episode were collected. Information was obtained for 153 of these people, covering their experience during the 6 months following discharge. A graphical method of depicting individuals' movements between services was devised and a number of measures were used to investigate the network-like features of the data. User outcomes were explored by examining the relationship of characteristics of service users to their location at 6 months after discharge. The results of the analyses show that the five sites were developing service configurations that facilitated transitions between health, social care and other services, and that individual needs were taken into account in the decisions made about which people transferred into which services. While the results cannot be said to show that joined-up government works, they are consistent with the argument that joined-up government goes beyond partnership-type concepts, and in practice, involves the creation of what might be termed integrated service networks.