HPPN Annual Conference 2013 Abstracts

Integrated Care and the Vulnerable: the technical, organisational and political challenges Andrew Gray
The presentation begins by elaborating three case stories of integrated care - or the lack of it. The first is an elderly couple, one with terminal cancer, the other vascular dementia. They have become part of the increasing numbers who are mixed economy consumers of health and social care. The second is a single mum who has learning disabilities identified only after she suffers repeat criminal victimisation. The third somewhat more successful as integrated care - because of extraordinary commitment by practitioners acting well beyond their roles - is an alcoholic, homeless offender who is impaired by a stroke. The cases are used to suggest some of the realities of forging integrated care. They reveal a tendency for care to be regarded as (a) exclusive professional domains in which practitioners realise vocations and make livings, (b) organisational possessions by which they realise individual and collective missions, and (c) revenue streams to be protected and enhanced. These tendencies present challenges for health policy and politics identified and analysed as technical, organisational, and political. The conclusion offers a triangulated approach to integrated care that addresses the service user in her or his physical and social context, manages the service pathway in its context and develops the governance of care as integrated systems rather than discrete interventions.

An exploration of how Clinical Commissioning Groups (CCGs) are tackling health inequalities in England Lynsey Warwick-Giles In 2010 the current coalition government was formed between the Conservatives and Liberal Democrats. Shortly after this, the White Paper Equity and Excellence: Liberating the NHS (2010) was published. This was the starting point for a large variety of policy documents being published relating the healthcare changes that were to happen within the UK. The recommended changes werent well received by healthcare professionals, wider organisations and the public. An official pause in the legislative process was called by David Cameron and Andrew Lansley (Secretary of State for Health) of the 4th April 2011 lasting for two months (Department of Health 2011). Following the pause a number of amendments to the initial policy proposals were outlined (Department of Health 2011). These included the newly developing GPCCs being restructured and renamed as Clinical Commissioning Groups (CCGs). CCGs would no longer consist of GPs alone; they would involve a wider membership including a nurse representative, a secondary care doctor and two lay representatives. Additionally, the Government took on board the recommendations of the Future Forum (June 2011) to make tackling health inequalities a duty for CCGs.

This research sets out to investigate health inequalities (HI). The concept itself is very complex with a wide variety of definitions that have been discussed within the literature. It was acknowledged early on within this project that because of the complexities and variations in peoples understandings and interpretations of HIs that a fundamental element of understanding how CCGs are tackling them would be underpinned by individuals own and the wider organisational conceptualisations of HIs. Through interviews and observations it was ascertained that HIs were being conceptualised and tackled differently across the three CCGs being researched. There were several common themes that were evidentially important to CCG members when describing the wider influences on their HI understandings. These included history, relationships and the role of Public Health. The aim of this presentation is to introduce and explore these findings in detail.

Are hospital consultants knights or knaves? The case of Clinical Excellence Awards

Mark Exworthy1, Paula Hyde2, Pamela McDonald-Kuhne3 1.Royal Holloway University of London 2.University of Manchester 3.Kingston University Email address M.Exworthy@rhul.ac.uk; paula.hyde@manchester.ac.uk; pbmcdonald@icloud.com Abstract Le Grands thesis of knights and knaves offers insights into the motivation of public sector employees. Whilst knights are individuals who are motivated to help others for no private reward, knaves are self interested individuals who are motivated to help others only if by doing so they will serve their private interests. Doctors exhibit both traits of motivation but explanations of the inter-relationship between them have remained neglected. We present an empirical elaboration of the `knights and knaves thesis in terms of clinical excellence awards (CEAs), the `financial bonuses which are paid to about half of all English hospital specialists and which can be as much as 75,000 (92,000) per year in addition to NHS salary. Through a textual analysis of responses to a recent review of doctors pay, we examine the `knightly and `knavish arguments used by professional, managerial and governmental stakeholders in defending or reforming these CEAs. While doctors promote their knightly claims, they are also knavish in shaping the preferences of and options for policy-makers and employers. Policy-makers continue to support CEAs but have proposed reforms to CEAs; employers have favoured a more radical approach. CEAs illustrate the enduring and flexible power of the medical profession in the UK in colonizing reforms to their pay, and also the subtle inter-relationship between knights and knaves in health policy.

Is it possible to improve hospital performance through a quality assessment programme? Findings from Lombardy Region Hospitals Evaluation Programme Michele Castelli, Durham University

Context Lombardy is an Italian Region that developed a health system model based on subsidiarity principle and the coexistence of public and private providers. In this model, evaluation is a key aspect to regulate and improve health care services. A Multidimensional Evaluation Programme of Hospital Performance was developed two years ago to improve hospital performance and, consequently, the overall regional health system performance. The aim of this analysis is to present this programme and to discuss some findings from the first two year implementation, with particular focus on hospital performance improvement. With more than 1.200.000 discharges analyzed this is an important case study at international level. Methods This analysis was developed in collaboration with Lombardy Region General Health Directorate. According to the five different performance dimensions of the Evaluation Programme, different methods were used to collect and analyze data: for example for the effectiveness dimension a statistical multilevel model has been used and the data source was the hospital discharge cards (administrative data source), whereas for the access dimension data from the regional customer satisfaction survey and data from the regional waiting list information system has been used and analyzed. Indicators for each dimension has been developed and for some of the dimensions the analysis was made at department level (for other dimensions at hospital level). With this analysis is possible to capture differences and improvement in hospital performance from the first to the second year of the Programme implementation. Results The Evaluation Programme consists of five dimension: effectiveness, standard evaluation, access, appropriateness and efficiency. It is possible to analyze the performance of each hospital in every one of those five dimensions or to compare different hospital performance for every single dimension. In addition it is possible to measure, for some indicators, results at department level within or between hospitals. The analysis is made on the last two years and so it's possible to compare and evaluate hospital performance from the first to the second year. Results are very interesting because show differences and similarities among similar hospitals or describe strengths and weaknesses within each hospital. From 2012, hospital performance (just for effectiveness evaluation) has an impact on the annual hospitals budget negotiation and we will present the 2012 results.

Discussion This Evaluation Programme was implemented after an accurate review of scientific literature in this field, several discussions with national and international health policy experts and an analysis of similar empirical experiences at international level, in order to build it on robust basis. Because this Programme is part of the regional health policy and planning legislation, hospitals results have an impact on their activity and have also a link to a percentage of their annual financial budget. Two most important lessons learned from this analysis are on the one hand that through a performance evaluation system is possible concretely to improve hospital performance (as data shows), on the other hand that a multidimensional evaluation is necessary to get an overall performance evaluation on hospital activity. Results demonstrate that this kind of performance assessment is an effective health policy tool and can improve health service delivery and the whole health care system. Marketing the market Calum Paton For twenty-five years, market reform has been sold to the English NHS as the answer to ill defined or even unasked questions, and as the solution to emotively framed yet essentially technical problems. We may contrast the role of the private sector which has helped shape what I have termed the London consensus in health policy (not least in that it is so distinct from that of Edinburgh, Cardiff or Belfast) with the failure to define and delimit the public interest. Not only has the revolving door between public and private sectors embraced both policy and personnel but, more significantly, health policy has been made short-termist, haphazard yet ideologically-rooted manner. The steely eye has been made the private sectors blurred vision, by contrast, has characterised public health policy making. The direction of travel is market, commercialisation and privatisation, especially in the delivery of care, yet there is chaos and counter-productive costliness in policy detail and implementation.

Developing Health and Wellbeing Boards and the invisibility of the environmental health profession. Surindar Dhesi The Health and Social Care Act 2012 and its preceding white papers have changed the public health (PH) structure and policy landscape in England. This has led to the creation of Health and Wellbeing Boards (HWBs) in upper-tier and unitary local authorities (LAs) with the aim of bringing health services and LAs together, to set the local strategic direction (for health and wellbeing), and to tackle health inequalities. HWBs have a minimum statutory membership including Clinical Commissioning Group (GP) representatives, Directors of Adults and Childrens Services, the Director of Public Health and an elected council member.

As part of these changes, the health services PH function was also returned to LAs for the first time following the restructure of 1974. At the time of the 1974 restructure, one PH profession, environmental health (EH) remained in LAs, although in two-tier areas they are located in the lower-tier. EH work is primarily preventative, tackling the social determinants of health such as living and working conditions; however there is no statutory place for the profession on HWBs. Using qualitative methods (semi-structured interviews, observations and document analysis), the research findings indicate that the role of EH is generally not well understood by HWB members and that the profession is doubly invisible both within and outside the rapidly changing PH community in which it operates. The presentation will discuss these findings in more detail, including what they mean for the future of EH in the new English PH system; the role of evidence-based practice; and the influence of the statutory HWB membership on the business and strategic priorities of four case-study HWBs.

The multiple purposes of policy pilots and their consequences Stefanie Ettelt and Nicholas Mays Policy pilots have been hailed as a modern approach to policy-making (HM Government, 1999). In England, the Coalition Government since 2010 and its New Labour predecessors have promoted policy piloting as a method for evidence-based policy-making (EBPM), in both rhetoric and practice. The 2003 Cabinet Office report Trying it out, for example, defines piloting as rigorous early evaluation of a policy (or some of its elements) before that policy has been rolled out nationally and while [it] is still open to adjustment in the light of the evidence compiled. However, by aligning piloting with EBPM, official documents tend to underplay the complexities of piloting. This paper offers a critical perspective on policy piloting. Using examples of three high-profile national policy pilots in health and social care in England, it argues that experimentation is only one of the motives for initiating pilots. Based on the analysis of interviews and documents, the paper suggests that other, less overt, but nonetheless legitimate, motives were also at play, such as creating opportunities to drive local policy implementation, to develop policy models that can be implemented elsewhere, and to demonstrate to others who policy can be implemented successfully. These purposes coexisted, generating significant ambiguity, which complicated the evaluation of these pilots and potentially impacted on their use to inform policy. The paper will explore the consequences of these different intentions and discuss how they both conflict with, and mutually reinforce, each other. It argues that policy piloting is a much more ambiguous, conflict-prone and risky activity than proponents of policy experiments tend to acknowledge.

Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS Kath Checkland

One of the key goals of the current reforms in the English NHS is to increase the accountability of those responsible for commissioning care for patients, whilst at the same time providing commissioners with greater autonomy. This presentation reports the findings from a study of the early stages of development of Clinical Commissioning Groups (CCGs) in England. We carried out detailed qualitative case studies in eight CCGs, using interviews, observation and documentary analysis to explore their multiple accountabilities. We found that CCGs are subject to a managerial, sanction-backed accountability to NHS England, alongside a number of other external accountabilities to the public and to some of the new organisations created by the reforms. In addition, unlike their predecessor commissioning organisations, they are subject to complex internal accountabilities to their members. The implications of this complex web of accountability relationships are discussed.

Professionalization as a Consequence of State Form: The Political Economy of Skill Development and Professionalization in the US and English Ambulance Services Heather Elliott Do states have the capacity to create professionalized occupations? If so, can these professionals be formed within an already dominant profession? This paper discusses and analyses the consequences of political centralization and decentralization as state forms on the professionalization of ambulance crews in the United States and England. In the United Kingdom, the centralized state constitutes a profession. Said another way, a workforce that is enshrined by the state is the workforce that takes over a domain. This is what has happened in the paid English National Health Service ambulance service. These providers have high degrees of professionalism and autonomy, and a low degree of volunteerism. The result is a fleet of professional, largely autonomous pre-hospital care providers. However, in the United States, state and policy decentralization has produced a mix of paid and unpaid ambulance service providers. While English and US crews undergo similar training courses and certification procedures, the mix of paid and unpaid ambulance service providers in the US has resulted in a floundering quasi-profession with an unstable mixture of salaried professionals and unpaid volunteers. Additionally, grassroots activism and emergency provider mobilization in the US has failed to produce systematic changes in the autonomy of ambulance crews. While decentralized American governments are much better at building a voluntary labor force than centralized governments, the centralized government of England is in a position to create useful and efficient professions that further organizational incentives to promote professional autonomy.