Anne McBride

Role redesign: new ways of working in the NHS

Purpose – To examine the introduction of role‐redesign in the NHS and highlight implications for employment relations.Design/methodology/approach – A 12‐month independent evaluation (2003‐2004) of a role redesign initiative in the NHS is reported. The study followed a developmental, case‐study design and included secondary data analysis, semi‐structured interviews and observations at five case‐study sites.Findings – The role redesign process involved four types of change to job content: skill‐mix changes; job widening; job deepening; and development of new roles. Each of these changes had implications for employment relations in terms of remuneration, management and accountability, and education and training.Research limitations/implications – The research involves one initiative in the NHS and was evaluating a developing programme. Whilst implications are suggested for efforts at role redesign generally the research specifically relates to NHS organisations.Practical implications – Three aspects of emplo...

The NIHR collaboration for leadership in applied health research and care (CLAHRC) for Greater Manchester: combining empirical, theoretical and experiential evidence to design and evaluate a large-scale implementation strategy

BackgroundIn response to policy recommendations, nine National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) were established in England in 2008, aiming to create closer working between the health service and higher education and narrow the gap between research and its implementation in practice. The Greater Manchester (GM) CLAHRC is a partnership between the University of Manchester and twenty National Health Service (NHS) trusts, with a five-year mission to improve healthcare and reduce health inequalities for people with cardiovascular conditions. This paper outlines the GM CLAHRC approach to designing and evaluating a large-scale, evidence- and theory-informed, context-sensitive implementation programme.DiscussionThe paper makes a case for embedding evaluation within the design of the implementation strategy. Empirical, theoretical, and experiential evidence relating to implementation science and methods has been synthesised to formulate eight core principles of the GM CLAHRC implementation strategy, recognising the multi-faceted nature of evidence, the complexity of the implementation process, and the corresponding need to apply approaches that are situationally relevant, responsive, flexible, and collaborative. In turn, these core principles inform the selection of four interrelated building blocks upon which the GM CLAHRC approach to implementation is founded. These determine the organizational processes, structures, and roles utilised by specific GM CLAHRC implementation projects, as well as the approach to researching implementation, and comprise: the Promoting Action on Research Implementation in Health Services (PARIHS) framework; a modified version of the Model for Improvement; multiprofessional teams with designated roles to lead, facilitate, and support the implementation process; and embedded evaluation and learning.SummaryDesigning and evaluating a large-scale implementation strategy that can cope with and respond to the local complexities of implementing research evidence into practice is itself complex and challenging. We present an argument for adopting an integrative, co-production approach to planning and evaluating the implementation of research into practice, drawing on an eclectic range of evidence sources.

Intersectionality: are we taking enough notice in the field of work and employment relations?

Intersectional analysis has been developing since its emergence from critical race feminism in the 1980s when it was used to conceptualize the inter-relationship of race and gender and, particularly, the experiences of discrimination and marginalization of black women in employment. While its contribution has been much debated within sociological and gender specific journals, its use still remains relatively limited within studies of work and employment relations. It is argued here that this field of study would benefit from greater engagement with and understanding of an intersectional approach to both the design and interpretation of research. Two lines of reasoning are put forward for this contention: firstly, that the intersectional approach contains an important caution against over-generalization that has been obscured; secondly, that separating the challenge for all academics to be more intersectionally sensitive from the methodological challenges of taking an intersectional approach brings the significance of intersectionality into sharper relief.

Making It Work: supporting group representation in a liberal democratic organisation

Providing oppressed social groups with rights of representation is one suggestion for counteracting bias towards privileged groups in society. In order to counteract a bias towards their white, male, heterosexual, able-bodied membership, a number of trade unions have provided social groups with resources to self-organize and represent their group interests to mainstream decision-makers. However, enabling group representation at the same time as individual representation is problematic in trade unions that are organized along liberal democratic lines. This case study of UNISON shows that while the union supported the self-organization of oppressed social groups, these groups were excluded from matters affecting pay and working conditions. The article argues that this outcome reflects the difficulty of reconciling the representation of social groups with the representation of individuals in a liberal democratic organization. The implications of this organizational framework are illustrated by contrasting the organizing strategies of two womens self-organized groups. While one strategy (the organization of women shop stewards) fits the prevailing organizational structure, the other (the organization of all women) attempts to be different and may have more potential for counteracting the bias towards privileged groups in the future. The article argues that a radical organizational framework is required if oppressed social groups are to gain real power within trade unions.

Lifelong learning, partnership and modernization in the NHS

The research involves examination of trade union involvement in training and education in the NHS which is explicitly linked to skills development, career structures and underpinned by a lifelong learning framework. The data derive from case studies of seven NHS organizations in England. Previous research indicates how UNISON-employer learning partnerships provide high-quality education programmes for non-traditional learners and represent a process of institution building. This paper indicates the challenges for workplace activists to be involved in skills development in the context of workforce modernization and in the absence of formal learning partnerships.

Crowded out? The capacity of HR to change healthcare work practices

This article analyses the role of HR in changing healthcare work practices. It uses a large, mainly qualitative, empirical study of a national HR initiative in England, document review and secondary sources to indicate how HR struggles to carve out a role for itself within the crowded space of workforce modernisation. The concept of regulatory space is used to indicate how government policy placing HR at the forefront of workforce change is challenged, first, by its complexity, and second, by the reality of regulating workforce practice at local levels. The highly technical nature of work organisation in healthcare, and constraints on the capacity and capability of the HR function, meant that such changes tended to be controlled and designed by clinicians, in contrast to the broad, strategic approach to HR envisaged by policymakers.

The role of patient-held alert cards in promoting continuity of care for Heart Failure Patients

Background: Patients with heart failure managed by community heart failure specialist nurses (CHFSNs) may have episodes of (often unrelated) ill-health managed separately in hospital. Inadequate communication and multi-disciplinary working between these different providers can impact on the effectiveness of care. Aim: This service improvement project explored the potential of patient-held alert cards to improve communication and continuity of care for heart failure patients moving between CHFSNs and hospital settings. Methods: Alert cards were distributed to 119 patients on a community case load for presentation at hospital or emergency department. Follow-up data were obtained from practitioners and patients at 12 months. Results: At 12 months, 38 patients from the CHFSN caseload experienced 61 hospital admissions. CHFSNs were informed of 80% of admissions by practitioners (61%) and family members (38%). They were also informed of 59% of discharges. Notification of admission by hospital staff increased from zero in the previous 12 months, to 19 notifications. CHFSNs were more involved with hospital care, and patients reported increased confidence with the alert cards. Conclusions: The study has shown that alert cards can increase the involvement of CHFSNs in the ongoing care and discharge planning process. They can also empower patients and carers to take an active role in their own care.

Skill-mix change and the general practice workforce challenge

Faced with an ageing population living with increasingly complex health needs and a shortage of GPs and nursing staff, primary care is experiencing unprecedented pressure. Workforce transformation based around new models of care and ‘skill-mix’ change in the form of 5000 new ‘non-medical roles’ to operate alongside GPs is an aspirational solution,1 though generating the right balance of GPs/non-GPs is not without controversy.2 Although practice nurses have been working in extended roles in general practice for a long time3 there are other ‘new’ roles emerging. These encompass both the integration into primary care teams of new types of professional (for example, physician associates), and existing professional roles operating in new ways (for example, paramedics), typically with the expressed aim of releasing the capacity of GPs.4 Thus, skill-mix change may be perceived as a straightforward and common-sense response, ‘substituting’ hard-to-recruit GPs with other, non-medical, health professionals. Recently, a House of Lords Select Committee on the sustainability of the NHS has added its weight to other reports4,5 calling for the greater inclusion of non-medical workforce working under new models of care.6 Re-designing the workforce through skill-mix change is a considerable challenge for organisations, which may indeed bring benefits.5 However, the literature indicates the necessity to understand the implications of changing skill-mix if it is to deliver on its promises. Skill-mix has been conceptualised in three ways to mean: (1) the range of competencies possessed by an individual healthcare worker; (2) the ratio of senior to junior staff within a particular discipline; and (3) the mix of different types of staff in a team/healthcare setting.7 Skill-mix changes have been classified into four broad role modifications:7 enhancement (for example, extension of a primary care practice nurse’s role …

The policy work of piloting: Mobilising and managing conflict and ambiguity in the English NHS

In spite of their widespread use in policy making in the UK and elsewhere, there is a relatively sparse literature specifically devoted to policy pilots. Recent research on policy piloting has focused on the role of pilots in making policy work in accordance with national agendas. Taking this as a point of departure, the present paper develops the notion of pilots doing policy work. It does this by situating piloting within established theories of policy formulation and implementation, and illustrating using an empirical case. Our case is drawn from a qualitative policy ethnography of a local government pilot programme aiming to extend access to healthcare services. Our case explores the collective entrepreneurship of regional policy makers together with local pilot volunteers. We argue that pilots work to mobilise and manage the ambiguity and conflict associated with particular policy goals, and in their structure and design, shape action towards particular outcomes. We conclude with a discussion of the generative but managed role which piloting affords to local implementers.

Creating sustainable employment opportunities for the unemployed

This article addresses challenges associated with creating sustainable employment opportunities for the unemployed and encouraging employer engagement in skills development and utilisation more generally. Survey and case study analysis of an initiative introduced by New Labour in the National Health Service England (NHS) provides evidence of employer reluctance to engage with a policy which addresses social exclusion and unemployment. Reasons are presented for this policy to implementation gap. This behaviour, in a buoyant economy, underlines a broader concern that voluntarism will be insufficient in the current economic climate to encourage employers more generally to adopt longer-term workforce development strategies. This reluctance to engage is compared with those NHS employers who were motivated to develop intermediate labour markets for the unemployed with explicit links to their internal labour markets, thereby providing opportunities for work experience and job progression. Implications are drawn from these contrasting behaviours as to how the state can encourage more employers to adopt progressive practices.