Rachael Addicott

Networks, Organizational Learning and Knowledge Management: NHS Cancer Networks

There has been increased interest in the UK in network-based modes of organizing in the public services, as opposed to markets or hierarchies. One supposed advantage of the network form is a greater capacity for the transfer of evidence-based or ‘best’ practices across the network and accelerated organizational learning. Such networks may have a knowledge management role and stimulate the formation of ‘communities of practice’. This article tests these arguments using data from a study of managed NHS cancer networks in London. The general pattern was for networks to concentrate on structural reconfiguration, while their knowledge management role remained marginal. Some alternative implications for future policy development are considered.

The NHS five year forward view: lessons from the United States in developing new care models

All political parties have endorsed NHS plans for greater integration of care in the next parliament. Stephen Shortell and colleagues use US experience to suggest what is needed to make it happen

How "accountable" are accountable care organizations?

BACKGROUND The establishment of accountable care organizations (ACOs) in the Affordable Care Act (ACA) was intended to support both cost savings and high-quality care. However, a key challenge will be to ensure that governance and accountability mechanisms are sufficient to support those twin ambitions. PURPOSE This exploratory study considers how recently developed ACOs have established governance structures and accountability mechanisms, particularly focusing on attempts at collaborative accountability and shared governance arrangements. METHODOLOGY Four case studies of ACOs across the United States were undertaken, with data collected throughout 2012. These involved 34 semistructured interviews with ACO administrative and clinical leaders, observation of nine meetings, and a review of documentary materials from each ACO. FINDINGS We identified very few examples of physicians being held to account as a collective and therefore only limited evidence of collaborative accountability impacting on behavior change. However, ACO leaders do have many mechanisms available to stimulate change across physicians. The challenge is to determine governance structure(s) and accountability mechanisms that facilitate the most effective combination of approaches, measures, incentives, and sanctions to achieve the goals of more accountable care. PRACTICE IMPLICATIONS Accountability structures and processes will need to be tailored to local membership composition, historical evolution, and current stage of development. There are also some common lessons to be drawn. Shared goals and incentives should be reflected through performance criteria. It is important to align measures and thresholds across payers to ensure ACOs are not unnecessarily burdened or compromised by reporting on different and potentially disjointed measures. Finally, emphasis needs to be placed on the importance of credible, transparent data. This exploratory study provides early evidence regarding how ACOs are establishing their governance and accountability arrangements and provides a foundation for future research and theory-building in this area.

Should diabetes be commissioned through multidisciplinary networks, rather than Practice Based Commissioning?

AIMS Diabetes is recognized as a complex, long term, largely asymptomatic condition requiring self management skills, a range of health care professionals and articulated health services. Diabetes Networks have been introduced to provide guidance from people with diabetes and local health professionals with different skills to ensure that diabetes care is well organized, sustainable and delivers quality care. We have considered the role of Diabetes Networks in the English setting. METHODS Drawing on studies of health service organization and health policy, we describe the context in which diabetes commissioning is currently occurring in England, the role of Diabetes Networks and key components for an effective Diabetes Network. RESULTS We have identified that Diabetes Networks are not currently mandatory and discovered policy approaches that are likely to work against safe, timely, integrated approaches to diabetes services with potentially harmful impacts on people with diabetes in the future. Practice Based Commissioning, where it sidelines Diabetes Networks, is a particular concern. We have identified key components of Diabetes Networks including explicit frameworks for leadership, membership, funding, decision making, communication and action. CONCLUSIONS Diabetes is a condition requiring collaboration between all involved. Diabetes Networks include patients and all relevant health professionals and should dictate what and how diabetes care should be commissioned within the local health economy.

Evaluating a complex system-wide intervention using the difference in differences method: the Delivering Choice Programme

Objectives We report the use of difference in differences (DiD) methodology to evaluate a complex, system-wide healthcare intervention. We use the worked example of evaluating the Marie Curie Delivering Choice Programme (DCP) for advanced illness in a large urban healthcare economy. Methods DiD was selected because a randomised controlled trial was not feasible. The method allows for before and after comparison of changes that occur in an intervention site with a matched control site. This enables analysts to control for the effect of the intervention in the absence of a local control. Any policy, seasonal or other confounding effects over the test period are assumed to have occurred in a balanced way at both sites. Data were obtained from primary care trusts. Outcomes were place of death, inpatient admissions, length of stay and costs. Results Small changes were identified between pre- and post-DCP outputs in the intervention site. The proportion of home deaths and median cost increased slightly, while the number of admissions per patient and the average length of stay per admission decreased slightly. None of these changes was statistically significant. Conclusions Effects estimates were limited by small numbers accessing new services and selection bias in sample population and comparator site. In evaluating the effect of a complex healthcare intervention, the choice of analysis method and output measures is crucial. Alternatives to randomised controlled trials may be required for evaluating large scale complex interventions and the DiD approach is suitable, subject to careful selection of measured outputs and control population.

Delivering better end-of-life care in England: barriers to access for patients with a non-cancer diagnosis

The End of Life Care Strategy (Department of Health, 2008) radically raised the profile of end-of-life care in England, signalling the need for development in planning and delivery, to ensure that individuals are able to exercise genuine choice in how and where they are cared for and die. Research has indicated that there have been continuing difficulties in access to high-quality and appropriate support at the end of life, particularly for patients with a diagnosis other than cancer. This article uses research findings from three case studies of end-of-life care delivery in England to highlight some of the barriers that continue to exist, and understand these challenges in more depth. Access to high-quality and appropriate end-of-life care has been a challenge for all patients nearing the end of life. However, the findings from this research indicate that there are several interrelated reasons why access to end-of-life care services can be more difficult for patients with a non-cancer diagnosis. These issues relate to differences in disease trajectories and subsequent care planning, which are further entrenched by existing funding arrangements.

Are inspectors’ assessments reliable? Ratings of NHS acute hospital trust services in England:

The credibility of a regulator could be threatened if stakeholders perceive that assessments of performance made by its inspectors are unreliable. Yet there is little published research on the reliability of inspectors’ assessments of health care organizations’ services. Objectives We investigated the inter-rater reliability of assessments made by inspectors inspecting acute hospitals in England during the piloting of a new regulatory model implemented by the Care Quality Commission (CQC) during 2013 and 2014. Multi-professional teams of inspectors rated service provision on a four-point scale for each of five domains: safety; effectiveness; caring; responsiveness; and leadership. Methods In an online survey, we asked individual inspectors to assign a domain and a rating to each of 10 vignettes of service information extracted from CQC inspection reports. We used these data to simulate the ratings that might be produced by teams of inspectors. We also observed inspection teams in action, and interviewed inspectors and staff from hospitals that had been inspected. Results Levels of agreement varied substantially from vignette to vignette. Characteristics such as professional background explained only a very small part of the variation. Overall, agreement was higher on ratings than on domains, and for groups of inspectors compared with individual inspectors. A number of potential causes of disagreement were identified, such as differences regarding the weight that should be given to contextual factors and general uncertainty about interpreting the rating and domain categories. Conclusion Groups of inspectors produced more reliable assessments than individual inspectors, and there is evidence to support the utility of appropriate discussions between inspectors in improving reliability. The reliability of domain allocations was lower than for ratings. It is important to define categories and rating levels clearly, and to train inspectors in their use. Further research is needed to replicate these results now that the model has been fully implemented, and to understand better the impact that inspector uncertainty and disagreement may have on published CQC ratings.

The organizational context and use of routine data for cancer service management

The authors studied the use of routinely available data by four cancer networks in England. Data use was not well developed, but beneficial structures included commitment by a full-time information officer, enthusiasm of a clinician with professed interest in multiple sources of information, and good links with external networks and clinical service groups. Policy-makers should support organizations where data are valued and integrated into performance.

The governance of pluralist health care systems: An initial review and typology

We here argue that study of governance systems within increasingly pluralist health care systems needs to be broadened beyond traditionally public sector orientated literature. We develop an initial typology of multiple governance systems within the English health care sector and derive exploratory questions to inform future empirical investigation. We add to existing literature by considering the coexistence of – and possible tensions between – multiple governance systems in a pluralised health and social care system.

Authors' reply to responses.

We thank those who have commented on our article.1 2 3 Our article had two main aims: to acknowledge that some of England’s health policy leaders see commonalities (as well as differences) between England and the US’s efforts to integrate care, and to share some early learning …