Rod Sheaff

User involvement in clinical governance

Objectives To investigate the involvement of users in clinical governance activities within Primary Care Groups (PCGs) and Trusts (PCTs). Drawing on policy and guidance published since 1997, the paper sets out a framework for how users are involved in this agenda, evaluates practice against this standard and suggests why current practice for user involvement in clinical governance is flawed and why this reflects a flaw in the policy design as much as its implementation.

The Role of Action Research in the Investigation and Diffusion of Innovations in Health Care: The PRIDE Project

In this article, the authors discuss the role of action research in relation to the investigation and practical implementation of innovations in health care. The diffusion of innovations is an essential component of the modernization of health services worldwide. However, the literature shows that it is not an easy process to research. A paradox is noted that although action research has much to offer, it has had only a limited impact in the innovation field. Drawing on an example of a project in the United Kingdom, the authors discuss whether action research is a valuable method in the study of the diffusion of innovations. They analyze its strengths and limitations as a “whole systems approach” that combines researching with developing and diffusing innovations. They argue that it is best suited to the study of innovation diffusion where there is a need for high level of adaptation in each new setting.

Some National Service Frameworks are more equal than others: Implementing clinical governance for mental health in primary care groups and trusts

This paper reports the findings of a study concerned with the way in which Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) engaged with the Mental Health National Service Framework (NSF) as part of their remit to implement clinical governance. A qualitative multiple case study is reported which used semi-structured interviews and documentary analysis in a purposive sample of 12 PCG-Ts in England. The study found a general awareness of and support for the Mental Health NSF among PCG-Ts. In some localities the NSF acted to reinforce existing local developments in primary care mental health. However, compared to the NSF for Coronary Heart Disease a number of difficulties in responding to the Mental Health NSF were identified. These related to the perceived clinical status and complexity of managing mental health problems at practice level (e.g. familiarity with and competence of General Practitioners (GPs) in managing the conditions), inter-agency working, clinical governance training and the feasibility of producing clear demonstrable mental health outcomes as part of performance management. While the NSF for mental health presents opportunities for establishing the principles of quality assurance and improvement in the area of mental health, it is in danger of being marginalized in the clinical governance agendas of new PCTs, because of an inability to compete on an equal footing with other clinical priorities. While the partial demedicalisation of mental health is increasingly recognised as desirable for policy and therapeutic reasons the corollary is that it is harder to implement non-medicalised forms of care through the essentially medicalised apparatus of clinical governance. In order to deal with the complexities and challenges posed by the mental health agenda targeted support and resources are needed to promote clinical governance developments within primary care organisations.

Marketization, Managers and Moral Strain: Chairmen, Directors and Public Service Ethos in the National Health Service

Survival of the public service ethos in Britain has been called into question following introduction of the ‘new public management’ and marketizing reforms in much of the public sector. This article examines how these developments have occurred in the NHS, using survey data to analyse NHS board members’ substantive ethical values. Unexpectedly the results suggest that NHS board members with a predominantly NHS background appear less ethically conservative, more flexible and less risk–averse than those recruited from non–NHS backgrounds; and that as yet the NHS management ‘culture’ is not very homogenous in respect of ‘business ethics’. The NHS reforms also appear to accentuate the tensions between transparent public accountability in NHS management and incentives not to publicize certain types of information. Recent codification of NHS ‘business ethics’ can be understood as an attempt to buttress the public service ethos against the increased moral strains of a quasi–market.

Is GP Restratification Beginning in England

English National Health Service general practice is being restructured through the introduction of primary care groups (PCGs) and trusts (PCTs), and the personal medical services (PMS) schemes. Theories of GPs’ professional organization have to be modernized accordingly. Past theories have tended to concentrate on the occupational level rather than consider the effects of different forms of market and quasi–market on practitioners’ income and their ability to control their everyday practice. This paper extends the theory of professionalization, as an occupational group’s strategy for control over its work, to cover these matters, and thereby hypothesizes an explanation of GP responses to current changes in NHS primary health care. Case study data from four PCGs and four PMS pilots suggest that general practitioners are responding in some cases by defending enclaves of traditional general practice; in others by concentrating on clinical rather than managerial interests; and in others again by forming a new dominant coalition with NHS managers. Restratification seems to be beginning in NHS general practice although other policy developments may yet prevent it. Researchers should monitor this potentially important change as PCTs form.

Development of an information source for patients and the public about general practice services: an action research study

Objective  The publication of information about the performance of health‐care providers is regarded as central to promoting greater accountability and empowering patients to exercise choice. The evidence suggests that the public is not very interested in accessing or using current sources of information. This study aimed to explore the information needs of patients in the context of UK primary care and to develop an information source about general practice services, designed to be usable by and useful to patients.

Public service responsiveness to users’ demands and needs: theory, practice and primary healthcare in England

Analyses and policy statements about publicly funded services frequently distinguish ‘demands’ from ‘needs’. The distinction has been challenged, calling into question the coherence of formulating welfare policy and evaluating public services in terms of needs. This paper explicates the conceptual distinction between demands and needs in terms of derived demand and information asymmetry. ‘Needs’ can be defined as ‘rational demands’, where ‘rational’ means ‘consistent and evidence–based’, and ‘demands’ as ‘desires’ rather than ‘effective (i.e. economic) demand’. On that basis, practical demand management in needs–based public services would require: 1. Knowledge of users’ demands for services; 2. Content analyses of users’ demands to identify any misinformed demands; 3. Conversion of any misinformed demands into evidence–based specifications of needs; 4. Formulating coherent, evidence–based demands on behalf of users who cannot to do so themselves. A study of English NHS Primary Care Groups explores the problems which authorities responsible for publicly funded services face in undertaking these activities. Demand management receives low priority in terms of the incentives and intellectual resources applied to it. Needs assessment has higher priority but is regarded as a branch of evidence–based professional practice, controlled by professionals rather than responsive to users. This separation tends to defeat the purposes of needs–based public services.

What is ‘primary’ about primary health care?

In many countries health policy and health system reforms are giving primary health care (PHC) a more prominent role in the health system. As a result, policy towards PHC is becoming more contested and is posing bigger and more contradictory demands of PHC (e.g. that PHC should at once be more accessible and of higher quality and cheaper). International and professional bodies have responded to the debates about what the role of PHC should be partly by promulgating redefinitions of ‘primary health care’. However, such definitions tend simply to assert a policy standpoint of their own, thereby begging the policy questions noted above. This paper tests some better-known current definitions of ‘primary health care’ against various criteria of validity, including the requirement not to prejudge the aforementioned policy debates. It then constructs a fresh definition from the materials which survive that test and from a general theory of the function of health care. The resulting definition is:Primary health care: goods or services which individuals obtain for maintaining their personal functioning or preventing pain; which they can access directly and receive in settings which allow them to continue their other normal activities of daily life at home and (when applicable) at work.Whilst its present conclusions relate specifically to PHC, the paper’s method for generating and testing definitions applies to health services research generally.

Marketing in the national health service: Prospects and variants

With the implementation of an internal market in the UK National Health Service (NHS), interest in marketing NHS services is growing. Yet marketing practice in other sectors of the economy, and the experience of other markets in health care, raise doubts and objections as to whether marketing should be introduced in the NHS at all. Some of these objections have force, and there are important structural differences between the NHS internal market and conventional markets. Simply copying conventional marketing methods is therefore unlikely to be an effective, or even a desirable, approach to marketing in the NHS. Specific forms of marketing are required for the NHS and these forms differ for purchasing organizations, for commercialized health care providers (including NHS trusts), and for directly‐managed NHS services. Differences between these variants can be illustrated by considering the different ways in which a generic model of marketing would have to be amended for each case. The differences also sugg...

A survey and audit of the first ‘Guides to Local Health Services’ produced by Primary Care Trusts in England

Background  Providing more information for the public about the range and quality of health services is an important part of improving accountability, quality and public responsiveness. Most sources of information to date have failed to address the information needs of people about their local services. The launch in England in 2002 of a new publication, Guides to Local Health Services, was designed to address this deficiency. We conducted an audit of the first Guides, and surveyed those responsible for their production, in order to examine the Guides’ development, content, presentation and dissemination, and to critique the purpose of the initiative.