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Über dieses Buch

This book examines how healthcare organisations shape, adapt and resist developments in healthcare policy and practice. This is an international text bringing together contributions from around the globe and covers a wide range of different discussions in relation to the policy/practice gap.





The first few months of 2010 were the coldest that the UK had experienced in 30 years. Heavy snow had covered many areas and had brought the country to a standstill. Then in early April the snow thawed as the sun came out to welcome the delegates to the 7th Biennial in Organisational Behaviour in Health Care (OBHC) conference, held in the pleasant environs of the University of Birmingham’s Edgbaston campus. This conference is a key meeting for members of the Society for the Study of Organising Health Care (SHOC) and was highly successful, attracting over 150 academics and practitioners from across the globe with an interest in understanding heath care organisations and change. The title of the conference was ‘Mind the Gap: policy and practice in the reform of healthcare’. Visiting academics were invited to share their expertise, and present and discuss papers that explored how health care organisations shape, adapt and resist developments in health care policy and practice.
Helen Dickinson, Russell Mannion

The Role of Professionals in Implementing Policy


1. The Lost Health Service Tribe:In Search of Middle Managers

This chapter suggests potential consequences for the NHS of widespread denigration of middle management. It is based on ethnographic research in the UK NHS. In 1994 Tony Watson published In search of management, continuing an academic preoccupation with elaborating the lived experience of being a manager. This chapter derives from the opening phases of a study in this tradition. He argued that managers, in shaping their own identities, also shaped organisational work activities and we extend this argument to demonstrate that negative associations to middle managerial identity have the potential to allow for strategic gaps in co-ordination at the middle reaches of NHS organisations as managers have to handle increasingly complex, fluid and heavy workloads, while facing daily challenges from other NHS stakeholders.
Paula Hyde, Edward Granter, Leo McCann, John Hassard

2. Managing the Psychological Contract in Health and Social Care: The Role of Policy

Research suggests that a well managed psychological contract can have positive benefits for both the organisation and the employee, including increased levels of commitment (Bartlett 2007; Guzzo et al 1994) organisational citizenship behaviour (Turnley et al 2003) and staff retention (Rousseau et al 2006). The psychological contract can be shaped by national and local policies, and how managers interpret, inscribe and implement these. There has been little exploration of psychological contracts in a health and social care setting, nor the role of policy, or through a qualitative lens.
Delia Wainwright, Sally Sambrook

3. Autonomy in Health Care Practice: A Paradise Lost?

There once was a time when professionals had complete autonomy over their role, while resources were abundant. There were no constraints on the freedom to act, other than the professional standards and codes of practice associated with specific occupations. Professionals were unrelentingly committed to their work, driven by altruism and without any self-interest.
Peter L. Hupe

4. Affording Discretion in How Policy Objectives are Achieved: Lessons from Clinician Involvement in Managerial Decision-Making

Many countries continue to face challenges in public policy implementation. One explanation for this is the need for local knowledge and insight to inform effective policy interventions (Matland 1995). This arises due to variations in local challenges, structures and stages of development, necessitating adaptation of policy requirements, to facilitate success (Hjern 1982; Matland 1995). However, in spite of increasing recognition of the need for local tailoring, traditional topdown and hierarchical modes of policy-making and implementation retain an enduring influence (Cho et al 2005).
Aoife McDermot, Mary A. Keating, Malcolm J. Beynon

5. Comparing the Quality of Working Life of Doctors with Other Workers Across Europe

How does quality of working life in health care (particularly for doctors) in the UK compare with other sectors and between countries, especially in relation to pan European policies like the European Working Time Directive. In this chapter we summarise data from a wider European Union (EU) project (European Commission 2007) highlighting particular problems relating to hospital doctors in the UK.
Annabelle Mark, Suzan Lewis, Michael Brookes

The Role of Culture and Institutions in Implementing Policy


6. The Role of Organisational Identity in Health Care Mergers: An NHS Example

Organisational change driven by mergers, acquisitions, demergers, spinoffs, collaborative networks and strategic alliances have been a common feature of organisational life internationally for the past two decades and increasingly so in health care provision. As health care providers the world over are exposed to competitive market forces, consolidation has become more prevalent as they seek to realise economies of scale in the context of tighter and tighter financial constraints.
Niamh Lennox-Chhugani

7. Organisational Networks — Can They Deliver Improvements in Health Care?

Networks are increasingly being used as a mode of governance within public management, with various advantages claimed for them in the policy domain over and above traditional governance modes of markets and hierarchies. But are they as effective as claimed? How can one indeed begin to assess the ‘performance’ of such networks? In the first part of this chapter, we will review the current literature on performance assessment in relation to public services networks and outline a performance assessment framework. In the second part, we apply and develop the framework to a particular case – assessing performance in a UK health care network. We draw out the more general lessons in the conclusion which indicate the complexities of making such judgements.
Sue Dopson, Gerry McGivern, Ewan Ferlie, Louise Fitzgerald

8. Discourses in Health Care Policy: Comparing UK and Canada

Health care policy has long provided an arena for debate around themes of services restructuring and the challenges associated with implementation initiatives in the public sector (Dawson et al 2007). Increasingly, researchers have been concerned with unpacking the ‘gaps’ between policy and practice in the process of health care reform. Notably, it has been argued that whilst evidence-based medicine has transformed clinical practice by rendering it more effective, this trend has not been followed by a similar logic in health management and policy-making, ultimately resulting in significant discrepancies between policy and practice (Walshe and Rundall 2001).
Eivor Oborn, Michael Barrett, Aris Komporozos-Athanasiou, Yolande E. Chan

9. Patient Safety: Whose Vision?

This chapter problematises the concept of ‘patient safety’ and unravels how it is understood and enacted by acute Trust staff, both managers and health care professionals, in the NHS in England. In understanding patient safety we focus on what the concept means to staff at different organisational levels, as well as how it is linked to wider organisational processes, structures and strategy, exposing the diverse practices, cultural attributes, competencies and processes that are wrapped up in its meaning. In particular, it is suggested that much good practice supportive of patient safety may be ‘unseen’ and ‘tacit’ (Mesman 2007) and that many factors impeding safety may not be direct, or located at the frontline or ‘sharp end’ (Dixon-Woods et al 2009). A primary focus is on staff perceptions of what is ‘patient safety’; any perceived links with staff well-being; and, what circumstances might facilitate or prevent them from providing safe care. We explore whether patient safety is approached by Trusts as a strategic system-wide change, connecting formal and informal practices, processes, cultural attributes, competencies, staff well-being and broader contextual factors; or if patient safety improvement is tackled as ‘initiative-driven’, piecemeal policy, with poor connectivity to strategy?
Kathryn Charles, Lorna McKee, Sharon McCann

Case Studies on Implementation and Reform


10. Inside Foundation Trust Hospitals: Using Archetype Theory to Understand How Freedoms Translate into Practice

As part of National Health Service (NHS) system reform in England, a novel type of provider organisation, the foundation trust (FT), was introduced in 2004. FTs were awarded considerably greater operational and financial freedoms relative to other NHS trusts (that is, publicly funded hospital groups), with new governance arrangements that replaced national accountability with accountability to the local community. The intention of the FT policy was that these new organisational forms could then use their freedoms and new governance arrangements to innovate more effectively, and improve their performance in financial management, quality and responsiveness of services delivered. The FT policy was initially developed following observation of similar reforms in other countries, such as Spain, Denmark and Sweden. However, there is very limited publicly available evidence regarding the success of these international reforms.
Rachael Addicott, Francesca Frosini

11. Structuring Emergency Care: Policy and Organisational Behavioural Dimensions

This chapter takes an ethnographic approach, with the aim of advancing knowledge about emergency departments (EDs) and the theory of organisational behaviour (OB). The case study is the treatment of vulnerable patients in the ED. Patients from vulnerable groups – such as those with mental illness, older patients and those from culturally and linguistically diverse backgrounds – in general, fare worse in the ED, than do other patients (Dingwall and Murray 1983; Hwang et al 2006; Jeffrey 1979). Refugees, for example, face cultural, social, and linguistic barriers to accessing health services in countries of resettlement (Sheikh et al 2006). The worldwide problem of inadequate care received by particular groups of patients reflects inequitable health access for vulnerable groups, and is an important issue for policymakers working to reform health care. In seeking to understand how such inequitable treatment comes to occur, this chapter takes as its starting point the interconnections between hospital departments. Such a perspective is realised through direct observation in the ‘natural’, everyday setting of the hospital.
Peter Nugus, Mohamud Sheikh, Jeffrey Braithwaite

12. Chronicling Twenty Years of Health Reform in Czech Republic

Health care reform has reached epidemic proportions throughout the world. From Germany to Australia, all seem to be searching for the magic formula that will deliver high quality care at lower costs. Nowhere has this become more apparent than in the Czech Republic. While privatisation of the industrial sector led to social cohesion, the same was not true for the health care sector (Oswald 2000). In 1992, the Czech government introduced massive health system reforms in an attempt to shift its post communist delivery structure toward a Bismarck model (Roberts 2003). The resulting public-private system has been continuously modified with varying degrees of success and acceptance. By illustration, a failed effort to institute a diagnosis related groups (DRG) system, out of control health care costs, and renewed discussions of full privatisation contributed to the Czech government collapse in spring, 2009 when Prime Minister Topolanek and his cabinet were forced to resign (Stage 2010).
Sharon L. Oswald, Rene McEldowney

13. Achieving and Resisting Change: Workarounds Straddling and Widening Gaps in Health Care

The international movement to reform health care and improve patient safety encompasses a range of strategies. These strategies include restructuring (Braithwaite et al 2005), policy reform measures (World Health Organization 2005; Garling 2008; National Health and Hospitals Reform Commission 2009; Hurst 2010) and programmes to standardise practice (Pronovost et al 2006; Gawande 2009; Iedema et al 2006). A social movement approach has been used to promote large scale change to the way in which patient safety is perceived and enacted within and across health services and systems (Bate et al 2004). Examples of this approach include international campaigns such as Five Moments for Hand Hygiene (World Health Organization 2006) and 5 Million Lives Campaign (McCannon et al 2007).
Deborah Debono, David Greenfield, Deborah Black, Jeffrey Braithwaite

14. Taking Policy-Practice Gaps Seriously: The Experience of Primary Health Care Networks in Western Canada

What happens between the development of a broadly espoused public policy and its effective implementation? How do health care organisations actually implement government policies when those policies are of an over-arching nature, providing direction but few specifics? These questions are not new, but we still struggle to find answers that benefit both policy-makers and service providers.
Ann Casebeer, Trish Reay

15. A Very Unpleasant Disease: Successful Post-Crisis Management in a Hospital Setting

Research concerning accidents, crises, and other serious incidents has focused mainly on causes, and on crisis management. The implementation of change following such extreme events has attracted less attention, but is often problematic. This chapter examines the experience of Burnside Hospital, where an outbreak of the ‘superbug’ Clostridium difficile (C. diff) was successfully managed, resulting in a dramatic and sustained reduction in the incidence of infections. What are the implications for management practice and health care policy, and for further research?
Colin J. Pilbeam, David A. Buchanan

16. Conclusions

In this final chapter we shall attempt to draw together the range of contributions made in this book into a conclusion. This is never an easy task with edited collections and this is no exception given the vast\ terrain that the contributions have covered, geographically, conceptually, methodologically and practically. We should not really be surprised by this range given that health care organisations comprise a diverse range of stakeholders who hold different values, beliefs, attitudes and amounts of power. The main theme of the policy/practice gap in the reform of health care clearly resonated with contributors and underpins and binds together all of the chapters.
Helen Dickinson, Russell Mannion


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