Geoffrey Meads

The management of new primary care organizations: an international perspective

Management practice arising from parallel policies for modernizing health systems is examined across a purposive sample of 16 countries. In each, novel organizational developments in primary care are a defining feature of the proposed future direction. Semistructured interviews with national leaders in primary care policy development and local service implementation indicate that management strategies, which effectively address the organized resistance of medical professions to modernizing policies, have these four consistent characteristics: extended community and patient participation models; national frameworks for interprofessional education and representation; mechanisms for multiple funding and accountabilities; and the diversification of non-governmental organizations and their roles. The research, based on a two-year fieldwork programme, indicates that at the meso-level of management planning and practice, there is a considerable potential for exchange and transferable learning between previously unconnected countries. The effectiveness of management strategies abroad, for example, in contexts where for the first time alternative but comparable new primary care organizations are exercising responsibilities for local resource utilization, may be understood through the application of stakeholder analyses, such as those employed to promote parity of relationships in NHS primary care trusts.

How to Sustain Interprofessional Learning and Practice: Messages for Higher Education and Health and Social Care Management.

The principal aim of this article is to promote the more effective integration of interprofessional learning with practice developments in health and social care. Ten specific recommendations are offered for the successful management of recent central policies for collaboration at the interface of the higher education and service sectors. Presented in an ‘Ideal Type’ format they are derived from four qualitative studies linked to the evaluation during 2004–08 of the NHS ‘Creating an Interprofessional Workforce’ programme. These include an international literature review, semi‐structured interviews with a representative sample of higher education leaders, participant observation in local projects and focus groups. The research findings also indicated the need for central policy‐makers to take more account of both enabling cultural influences when seeking sustainable change and the new opportunities for integration that arise from the growth of Third Sector agencies in health and social care.

An evaluation of personal medical services: the times they are a changin'

The Personal Medical Services (PMS) pilot sites, launched in England in 1997 by the Secretary of State for the then Conservative government, introduced a local contract for primary care, aimed at promoting flexibility, innovation and policy participation. As part of the National Evaluation of PMS, this paper considers the professional and organisational relationships established between service providers working in those PMS sites which specifically set out to address inequalities in access to primary care for vulnerable populations. The introduction of PMS enabled a change of cultural values in primary care, particularly regarding GPs’ relationships with nurses and practice staff. However, PMS has not necessarily led to equal partnerships within primary care teams. Rather, in the selected sites evaluated new interprofessional relationships emerged. There was evidence of intra and interprofessional partnerships being forged, providing the basis for further improved intersectoral collaboration. There was also evidence that the GP based medical model made way for a community oriented/public health model with emphasis on health maintenance for the vulnerable.

Lessons from local engagement in Latin American health systems

Objectives To examine the management of recent policies for stronger patient and public involvement in Latin American health systems, identifying common features and describing local practice examples of relevance to the UK.

Positioning Children’s Voice in Clinical Trials Research: A New Model for Planning, Collaboration, and Reflection

Following the United Nations Convention on the Rights of the Child, there has been considerable growth in research with children about health and services that affect them. Creative methods to engage with children have also been developed. One area where progress has been slower is the inclusion of children’s perspectives in qualitative research in the context of clinical trials or feasibility studies. Addressing this gap, this article discusses experiences of, and reflections on, the process of researching children’s views as part of a clinical feasibility study. The article considers what worked well and highlights remaining dilemmas. A new continuum of children’s engagement in research is presented, designed to assist researchers to make explicit the contingent demands on their research, and to suggest a range of techniques from within the broader fields of health, childhood studies, and education research that could be used to forward qualitative research in clinical contexts.

Extending primary care: potential learning from Italy.

Health systems across Europe are under increasing pressure to shift care outside hospitals and into community settings. The emphasis is on providing high-quality, coordinated care for a growing population of older patients and those with long-term conditions. Extended primary care is regarded as the key means of achieving such a shift. We report learning following exploratory visits to two sites in Italy, each providing an example of a primary care organisation with extended general practices, community health and local resource utilisation responsibilities. We draw out three areas of potential interest--shifting care from hospital to community settings, facilitating localism and enabling stable leadership--all of which appear to provide a means for local clinicians, managers and their communities to commission care according to local needs. We conclude by recommending that primary care researchers consider undertaking further work in Italy, building on this exploratory work and more systematically exploring the effects of such programmes.

Primary health care models: learning across continents

forms of primary care organization for their effective implementation. This has been apparent over the past decade in the UK through the transition from general practice fundholding models to the present NHS (National Health Service) primary care trusts. Equally radical developments in both the context and structures of frontline health service delivery have been evident internationally wherever the tenets of ‘Modernization’ have held sway. As a result there is now considerable scope for transferable learning between those countries, in every continent, that are now experimenting with novel organizational developments in primary care. Typically these developments are part of attempts to revive not just local health systems but the role of the nation state as well. Although this may seem most obvious in the post dictatorship countries and emergent participatory democracies of Latin America there are also lessons, and fresh opportunities for reciprocal exchange, for practitioners and policy makers in the UK, where recent government guidance has pointed firmly in the direction of more diversity in both primary care provision and ownership (Department of Health, 2006). Such diversity is a commonplace globally in ‘modernizing’ health policies through their emphasis on exploiting previously unexplored cross sectoral collaborations and new interprofessional and practice partnerships. Together with innovations in governance, stewardship arrangements for public health and multiple forms of financing these represent a radical agenda for local resource management in today’s health systems. Over the past four years our fieldwork has taken us to thirty countries where this framework for policy reforms has applied since 1997 – when a Labour Government took office in the UK promising a ‘New NHS’ – and led to the identification of six different standard models of primary care organization (Meads, 2005). Each belongs to its particular cultural context. All, however, are also examples of the new corporate organizational developments that together signify the fundamental shift taking place in contemporary primary care, as it moves away from simple forms of uniprofessional partnership towards tomorrow’s world of complex stakeholder enterprises. The new forms of primary care organization correspond broadly with the six administrative regions of the World Health Organization, and the influence of the latter in steering national leaderships is sometimes not too difficult to detect.Across Sub Saharan Africa, for example, in countries such as Uganda and Kenya, the principles of Alma Ata and Health for All are enmeshed in the District Health System model; while the Washington based and impressively autonomous Pan American Health Organization has been positively assertive in its sponsorship of the Community Development Agency version of primary care for such countries as Peru, Costa Rica and Venezuela. In Europe the principle of subsidiarity has ensured more national control over domestic health policy developments. Nevertheless in recent years the Extended General Practice in the UK and elsewhere has grown in tandem with Managed Care organizational changes that have their origins in the USA, and which may now be seen translated into the operation of, for instance, Thailand’s competitive Contracting Units for Primary Care and New Zealand’s hybrid Primary Health Organizations, with their mix of private and public service professionals. Alongside the extended general practice, the managed care business, the district health system and the community development agency stands the most surprising of the contemporary organizational developments in primary care: the reformed polyclinic. Its capacity to attract co-payments and private specialist contributions that can even include, in the likes of Bolivia and Belarus, alternative Primary Health Care Research and Development 2006; 7: 281–283 doi: 10.1017/S1463423606000375

Community governance in primary health care: towards an international Ideal Type

Against a global background of increased resource management responsibilities for primary health care agencies, general medical practices, in particular, are increasingly being required to demonstrate the legitimacy of their decision making in market oriented environments. In this context a scoping review explores the potential utility for health managers in primary health care of community governance as a policy concept. The review of recent research suggests that applied learning from international health systems with enhanced approaches to public and patient involvement may contribute to meeting this requirement. Such approaches often characterise local health systems in Latin America and North West Europe where innovative models are beginning to respond effectively to the growing demands on general practice. The study design draws on documentary and secondary data analyses to identify common components of community governance from the countries in these regions, supplemented by other relevant international studies and sources where appropriate. Within a comprehensive framework of collaborative governance the components are aggregated in an Ideal Type format to provide a point of reference for possible adaptation and transferable learning across market oriented health systems. Each component is illustrated with international exemplars from recent organisational practices in primary health care. The application of community governance is considered for the particular contexts of GP led Clinical Commissioning Groups in England and Primary Health Networks in Australia. Some components of the Ideal Type possess potentially powerful negative as well as positive motivational effects, with PPI at practice levels sometimes hindering the development of effective local governance. This highlights the importance of careful and competent management of the growing resources attributed to primary health care agencies, which possess an increasingly diverse range of non-governmental status. Future policy and research priorities are outlined. Copyright

From pastoral care to public health: an ethnographic case study of collaborative governance in a local food bank

Abstract: Background Escalating urgent demand for subsistence, especially from young families, has been matched by the rapid increase in food bank outlets in the United Kingdom. The majority of these have originated in faith based initiatives, initially through small back street service outlets and, more recently as frontline social enterprises contributing nationwide to social security and welfare provision. Objective The article seeks to describe, define and discuss developments in collaborative governance from 2006 to 2016 in a local food bank. An established analytical framework for community services is employed to identify implications for public health. Method An ethnographic approach is employed. Data sources include structured research diary notes, agency agendas, local surveys and stakeholder workshops, and participant observation. Key events are identified through five yearly time interval assessments of critical decision making between 2006 and 2016. Results The local narrative indicates a progression towards wider representation in the collaborative governance arrangements, with a corresponding advance in awareness of food poverty and public health issues. Initially neglected these emerge with the changes in organisational status from informal volunteers group to complex formal organisation with specialist management functions. Increases in scale and differentiation also apply to the broader profile of Christian agencies and shift towards control by those with stronger physical and institutional structures. However, although the local service has helped raise awareness of food poverty in civic agencies scriptural sources remain more influential than secular strategies.

Wellbeing Agencies in the High Street: The Rebirth of Primary Health Care?

This scoping review combines a secondary data analysis of global exemplars with case studies of increasingly diverse wellbeing agencies in highly ‘liveable’ Winchester and Melbourne. It identifies a research agenda, which includes the roles of social and commercial enterprises and their needs for effective community governance.