Health Policy and Politics Network Annual Conference

30 August 1 September 2017

Green Templeton College, University of Oxford

Abstracts

Primary care co-commissioning: Implications for the sustainability of CCGs as clinically-led

organisations?
Imelda McDermott, Lynsey Warwick-Giles, Oz Gore, Valerie Moran, Donna Bramwell, Anna
Coleman, and Kath Checkland

The Health and Social Care Act 2012 gave GP-led Clinical Commissioning Groups (CCGs)
responsibility for commissioning the majority of health care services for their registered
population. However, responsibility for commissioning primary care services was given to
NHS England (NHSE) to avoid conflicts of interest and because of a perceived need for a
standardised and consistent approach to commissioning. It soon became apparent that
NHSE was struggling to move beyond a transactional approach to commissioning, focused
upon payments and contract management. When Simon Stevens took over as the Chief
Executive of NHSE (April 2014), he advocated transferring primary care commissioning
responsibilities from NHSE to CCGs. The guidance gives CCGs the flexibility to set up their
decision-making committee, including the committee membership and its roles and
responsibilities. However GPs must not be in the majority to mitigate conflicts of interest.
The primary care co-commissioning committee need to have a lay and executive majority.
Moreover, with increased appetite in GP-led provider organisations, it makes more sense for
GPs leaders to focus their efforts as providers of services rather than as commissioners.
These changes may have significant implications for the sustainability of CCGs as clinically-
led commissioning organisations.

Is there really a crisis in general practice?

Steve Iliffe

During 2016 public attention focused more on the apparent crisis in NHS Accident &
Emergency departments and less on a proclaimed crisis in general practice, which emerged
as a policy problem in 2014 and only subsided with the introduction of a new GP contract in
early 2017. This presentation will attempt to answer the following questions about this
proclaimed crisis: are GPs are having more consultations, is the number of GPs is going
down, and are GP earnings declining. This analysis uses three different understandings of
the word crisis: a common, journalistic usage, Kleins view of crisis in the NHS as
dramaturgy (dramatic composition for political effect), and Gramscis concept of organic,
system-shaking, crisis. The data sources used to answer these questions include QResearch,
CPRD (Clinical Practice Research datalink), ResearchOne, the Centre for Workforce
Intelligence, the Health and Social Care Information Centre, the Public Accounts Committee,
the National Audit Office, the GP Worklife Survey and QOF data returns, political
commentaries from the BMA and the Royal College of GPs, reviews from DeLoitte, the Kings
Fund and the Nuffield Foundation, and selected academic publications. If crisis is
understood as approaching a significant turning point, then general practice is in a critical
transition from small-scale to large-scale work units, with differentiation of the clinical
workforce into owners and employees and a widening income gap between the two. An
underlying problem of recruitment and retention may further destabilise the discipline of
general practice. There is no shortage of dramaturgy, which may exacerbate the recruitment
and retention problem, but there is no evidence of an organic crisis in general practice that
will affect the whole NHS.

Challenges and Facilitators for Health Professionals Providing Primary Healthcare for
Refugees and Asylum Seekers in High-Income Countries: A Systematic Review and
Thematic Synthesis of Qualitative Research
Luke Robertshaw, Surindar Dhesi, and Laura Jones

Background: Countless people continue to be displaced due to conflict or persecution.

Many seek refuge in high-income countries, arriving with complex physical and psychological
health conditions. Health systems and professionals in host countries endeavour to provide
care; however, inequalities in access and quality of care persist. Primary healthcare
professionals play a crucial role in service provision for this group and some qualitative
studies have explored their experiences.
Aims: To thematically synthesise primary qualitative studies that explore challenges and
facilitators for health professionals providing primary healthcare for refugees and asylum
seekers in high-income countries.
Design: Systematic review and qualitative thematic synthesis.
Methods: Searches of MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science. Search
terms were combined for qualitative research, primary healthcare professionals, refugees
and asylum seekers, and were supplemented by searches of reference lists and citations.
Study selection was conducted by two researchers using pre-specified selection criteria.
Data extraction and quality assessment using the CASP tool was conducted by the first
author. A thematic synthesis was undertaken to develop descriptive themes and analytical
constructs.
Results: Twenty-six articles reporting on 21 studies and involving 357 participants were
included. Eleven descriptive themes were interpreted, embedded within three analytical
constructs: Healthcare encounter (trusting relationship, communication, cultural
understanding, health and social conditions, time); Healthcare system (training and
guidance, professional support, connecting with other services, organisation, resources and
capacity); Asylum and resettlement. Challenges and facilitators were described within these
themes.
Conclusions: A range of challenges and facilitators have been identified for health
professionals providing primary healthcare for refugees and asylum seekers that are
experienced in the dimensions of the healthcare encounter, the healthcare system and
wider asylum and resettlement situation. Comprehensive understanding of these challenges
and facilitators is important to shape policy, improve the quality of services and provide
more equitable health services for this vulnerable group.

Refugee Health in Germany

Christine Frber

Background: Germany currently is the country of refuge for more than 1 Mio refugees. This
is a challenge to health care, public health and health promotion. They require information,
competences and access to care, to remain and become healthy. The specific situation of
forced migration, the burdening situation of emergency housing and the language barrier
form huge challenges.
Focus: The presentation gives an overview on access to care and treatment, living conditions
(housing, nutrition, financial situation) and gives perspectives for setting-related health
promotion for refugees conducted in Hamburg, Germany.
Methods: The presentation combines a policy- analysis on the current situation in Germany
with experiences from a peer-to-peer health promotion facilitator program, in which the
author has collaborated with refugees in Hamburg, Germany, since September 2015 up to
today. Health needs, challenges and possible solution strategies regarding nutrition,
hygiene, mental health, health promotion and access to care are identified.
Results and Lessons Learnt: Refugees in Germany do not get access to health care equal to
Germans. Although some groups (pregnant women and children) are eligible to equivalent
care, bureaucratic procedures provide decisive barriers. Hamburg has introduced a relatively
unbureaucratic way of managing access to care, an insurance card, which will be presented
as a case. Housing conditions for many are not meeting adequate standards, with hygiene
and nutrition posing challenges, and abilities for education or physical activity are decidedly
limited. Peer education programs which bring together university students and refugees
provide a pathway to local system. Language management, financing and administrative
barriers can be identified as major challenges here. As the German health care and welfare
system are very different from UK structures, major structural issues are identified in the
talk to make the information accessible for a UK audience.

Implementing Culture Change in Health Care: the case of NHS Inquiries

Martin Powell, Russell Mannion, and Huw Davies

There is a large literature on the importance and role of culture and culture change in health
care. The latest high profile recognition of this in the NHS is the Francis Report of 2013 into
events at the Mid Staffordshire Foundation Trust, which argued that a fundamental culture
change is needed However, the notion of culture as problem and culture change as
solution is part of a longer history in the NHS. It can be argued that culture change
arguments date back to at least the Griffiths Report of 1983. However, the clearest line of
argument can arguably be seen in Inquiries into poor clinical care in the NHS.
This paper examines material on culture and culture change within the NHS since the
Kennedy Inquiry into the Bristol Royal Infirmary in 2001. It examines NHS Inquiries and the
Responses to these by government. In more detail, the source documents are the Inquiries
into the Bristol Royal Infirmary; Ayling; Kerr/Haslam; Shipman; Mid Staffordshire I (Francis
2010); and Mid Staffordshire II (Francis 2013). Through a (simplified) form of Qualitative
Keyword Analysis, we explore what, how and who questions of culture and culture
change in health care contexts. The what question refers to the nature of the cultural
problem and proffered solution (from what to what?). The how question focuses on
suggested strategies for promoting beneficial culture change and renewal. Finally, the who
question examines agency and implementation (who is to make the changes?). It can be
seen that there is a wide range of problem and solution cultures. However, there is very
limited focus on suggested strategies for culture change. Finally, there appears to be even
less attention on who is responsible for making the changes. It can be concluded that
cultural solutions are easy to recommend; almost impossible to implement.

Fake News and our Care System

Richard Bourne

The crisis in care is now rarely out of the mainstream media, often with lurid headlines and
dramatic stories. There are repeated calls for reviews into the funding of the NHS and social
care, and attempts to reach political consensus on making our system sustainable. There is
also much information and no shortage of analysis and comment. This presentation
illustrates how evidence is shaped by the fake news spread by pressure groups of all
kinds. Fake news is when an anecdote becomes evidence or one fact makes a whole
case. Examples of fake news that will be presented include: the reporting of the Mid. Staffs
crisis; the costs to the NHS of the internal market; the bankrupting effect of PFI costs; the
extent of privatisation; the possibility of demand management; the savings from service
integration; the benefits of hospital mergers; and the essential role of reconfiguration to
improve the quality of care. I have worked extensively across the NHS and Local Authorities
over the last 20 years as a management consultant and in executive and non-executive
roles. I have carried out numerous reviews (well over 100) of major projects and
programmes and also worked on policy development.

How, and why does capitation impact on dentists behaviour: a rapid realist review
Tom Goodwin, Paul Brocklehurst, Hall, B., and Williams, L.

Background: From a formal evaluation of a capitation-based dental pilot, as part of a

National Institute of Health Research funded project (HS&DR 14/19/12), data collected from
a series of qualitative interviews suggest that dentists may behave differently as a result of
the pilot in a way that conflicts with the results of previous studies. As such, our aim here
was to develop a theoretical explanatory account as to how and why capitation pilot can
affect dentists behaviour in different ways.
Methods: Drawing on realist methodology, a rapid realist review (RRR) was conducted. This
involved searching the literature to inform an initial programme theory as to how and why
the capitation pilot impacted on dentists behaviour. Three databases were searched
between 1948 and 2017. Citation searching and snowballing was also used.
Results: Our search returned 1583 articles that were subsequently narrowed down to 10
relevant papers, providing evidence to either support our initial programme theory or to
develop it further.
Conclusion: Employing the rapid realist review approach enabled us to develop and inform
an initial programme theory. In essence, our theory postulates that dentists are affected by
a number of competing interests and incentives which can influence their behaviour in a
variety of ways. We suggest that further research is required to understand the causal
mechanisms associated with this divergent behaviour as well as the underlying contextual
conditions that activate these mechanisms.

Doing the right thing or doing the thing right? How PRINCE2 shapes health care
Sara Shaw, Trish Greenhalgh and Gemma Hughes

New models of care, care home vanguards and innovation test beds. These are just a few
of the initiatives being pursued in Englands National Health Service (NHS). They reflect
wider changes in the organisation of the public sector that encourage short-term, focused
projects that frequently de-couple the change process from the wider context. The
dominant research interest in such projects has been on questions of implementation and
outcome (e.g. how are project aims achieved). Far less attention has been given to questions
of process, for instance, how do projects progress, how are they managed, and how does
this shape the kind of work that does and doesnt get done? This paper asks precisely
these questions in the context of health care. It has emerged from repeated observations
that those working in the health service are often guided by the means of delivering projects
rather than the hoped for ends. As one clinician told us in a study of health-related IT, The
problem is the mindless effect this management style has on everybody, they cant think
straight when told to do things in this way. In other words, far from being a neutral,
technocratic process, we suspect that the approach to managing healthcare projects plays a
significant role in shaping health care. Project management approaches are ubiquitous in
the NHS. We have elected to focus on PRINCE2 (PRojects IN Controlled Environments),
which is a structured project management methodology developed by the UK government
and widely used in NHS projects. The PRINCE2 method purports to offer best practice
guidance on project management, and is marketed as relevant for any project in any area of
any scale. Drawing on interpretive policy analysis and linguistic ethnography (Shaw and
Russell 2015), we present findings from an auto-ethnography of PRINCE2 training, adapting
traditional participant observation methods to study the meanings and experiences manifest
in an online PRINCE2 course. Our findings focus on three areas. Firstly, language plays a key
role in PRINCE2 in promoting and sustaining ideas of a market society (Mautner 2013).
Repeated use of terms such as suppliers, business products and assurance mechanisms
work to translate concerns over sickness or care into market-oriented language that is
focused on business cycles and oriented to creating value. This jars with values of
citizenship or public duty often associated with public welfare. Secondly, the principles
underpinning PRINCE2 draw on standardised, technocratic and linear views of the world,
with processes leading directly to outputs. This way of conceptualising change distances
those involved in project management from the human elements of managing. Finally, the
tools and templates inherent in PRINCE2 decontextualize projects from the very
communities they are (in theory) intended to serve. We conclude by reflecting on the
consequences of this project management work for health care.
References
Mautner G (2013) Language and Market Society. London, Routledge.
Shaw SE and Russell J (2015) Narrating healthcare planning. In Snell, Shaw & Copland,
Linguistic Ethnography: An Interdisciplinary Reader. Palgrave.

Leading Transformation in a Perfect Storm: Third sector influence in whole system change
Policies: NHS Five-Year forward view 2015, RightCare Value based health care,
Sustainability & Transformation planning
Tina Swani

The presentation delivers a lived experience over 24 months illustrating third sector
transformation and influence in whole system change to meet growing demands within
continued austerity including NHS solutions to reducing the predicted 2020/21 30bn deficit
between health care needs of the population and funding available. Through establishing
new organisational paradigms Tina Swani examines the position of the third sector in a
changing health environment in relation to value-based healthcare and sustainability and
transformation planning. The presentation is delivered from the experience of a Hospice
Chief Executive from a point in time where 3 significant financial risks simultaneously
materialised in November 2014, to a position where 8 service redesign projects were
launched by April 2016 with recognised impact on larger system solutions to growing health
demand at end of life and financial deficits in the health and social care economy. The
financial position shifted from a corporate anticipated deficit of 1m to a surplus of almost
0.8m and has led to national interest and influence.
http://www.ehospice.com/uk/ArticleView/tabid/10697/ArticleId/20541/language/en-
GB/View.aspx
http://www.edgemagazine.org/ceo-of-nhs-england-backs-charity-vision-for-hospice-care-
for-all.html
The presentation relates and reframes culture, coaching, change and marketing theory
whilst delivering learning from mistakes and successes; how change was accelerated once
the shift from fear to possibility was achieved; and how the sustained focus on dignity,
experience and confidence of individuals/patients, families and carers has extended reach
by 25% by 2017. Whilst each of the financial risks had been anticipated in isolation, and at
different times, together they created a perfect storm with the additional pressure of
growing demand:
Legacy income diminished for a sustained period of 3 months
Three NHS Clinical Commissioning Groups initiated procurement for End of Life Care
Predicted decline in voluntary income due to redesign of the fundraising team
The author delivers a real story, stimulating debate and illustrating how change was
accelerated through self-directing teams that have transformed working practice to enter
new market space with a tested target to double reach and demonstrate sustainability
through the Hospices Case for Change and Co-design. This incorporates a shift in
governance, partnerships, community based co-design and person-centred approaches.
The Case for Change has already achieved significant financial investment (including CCG
and major donor investment); early review to the CCG is already demonstrating evidence of
larger system transformation.

1. Produced a decision and change model using 3 sources Kotter, Z, Grow

2. Blue Ocean Strategy Creating new market space where competition is irrelevant Kim &
Mauborgne
3. A "perfect storm" is an expression that describes an event where a rare combination of
circumstances will aggravate a situation drastically, resulting in an event of unusual
magnitude
4. Hospice UK strategy 2017-2022 identifies that Hospices reach only 50% of those in need of
hospice care

Commercialisation in the NHS: a multi-level analysis of non NHS income

Mark Exworthy
With Simon Bailey, Sarah Lafond, Neil Lunt, Rakesh Mistry, Penelope Tuck
Co-authors surnames in alphabetical order

This paper explores the extent to which National Health Service (NHS) organisations in
England are becoming more commercial in their aims and practices. Here, we analyse the
income that NHS Trust have been earning from non-NHS sources. The growth of non-NHS
income has become more salient since austerity policies have been implemented since 2010
and regulations relaxed the proportion of non-NHS (`private) income that the NHS could
earn (since 2012). We present a multi-level analysis, by using national financial data from
235 NHS Trusts in England, then focusing on financial and documentary data from specialist
Trusts (which are often thought to be at the forefront of commercialisation), before finally
examining interview transcripts from staff in one such specialist NHS Trust. The paper
presents the findings in terms of a variation of Polanyis double movement, interpreted here
as the paradox whereby `private income is seen as essential to support the NHS as a public
service.

Providing health and social care: sources of alternative understanding

Andrew Gray

This presentation lightly shares experiences of working with practitioner development in

which the communication of ideas often struggles when drawing on orthodox academic and
practice sources. Communication of the same ideas seems much improved when
accompanied by alternative sources and media. The talk will illustrate some of these
mechanisms of alternative understanding that I have found effective. The mechanisms
include novels, poetry, drama, art, sculpture, and even the circus!
A Broken NHS? Privatisation and the health service in England
Vid Calovski

The NHS in England has been depicted as an institution which has political and social value
far beyond its purpose of providing a national system of state funded health care. Hence,
the passing and the implementation of the Health and Social Care Act (2012) reignited the
debate about the extent to which the national health service in England was being
privatised as it was seen as threat to the core principles of this sacred institution.
The aim of this paper is to focus on this recent legislation and its implications and
impact. However, the first part of the paper will analyse past health service policy
developments as they relate to the relationship between the private sector and the NHS and
what shaped these developments. The purpose is to provide a broad sociological context for
understanding the most recent legislation and assessing the extent to which it represented a
radical shift or an incremental policy change. The second part of the paper considers the
implications of the 2012 Act and the extent to which it has facilitated marketisation and/or
privatisation. Key elements of this legislation involved the setting up of clinical
commissioning groups (CCGs) which are led by general practitioners and extending the
choice of providers (public, private or third sector) which reflect the increasing emphasis on
choice and competition. The impact of these changes are examined through evidence from
a recent ethnographic study of decision-making of the newly set up CCGs about the extent
to which privatisation is taking place. This study followed the commissioning processes in
two CCGs and the decision-making regarding the choice of public or private provider. The
ethnography involved interviews with key informants including clinicians, managers and
policy makers as well as observations of significant CCG meetings. Findings show how CCGs
make decisions regarding selection of providers and the influences on these decisions. These
influences include those external to the organisation at the national level and those at the
more local level. The paper concludes by discussing the possible long-term implications of
the legislation, particularly considering the extent to which it may have indirectly, rather
than directly, encouraged a drift towards privatisation.

The impact of health policy reform on public health professional identity: a case of the
English Health and Social Care Act 2012
Alex Hall, Jon Hammond, Donna Bramwell, Anna Coleman, Lynsey Warwick-Giles, and Kath
Checkland

Public health became established as a distinct profession when dramatic increases of

infectious diseases during the industrial revolution led to an urgent need to improve
sanitation and health. However, public healths 150-year history has been turbulent,
characterised by uncertainty in scope, and there remains no internationally-agreed
definition. In the UK, repeated reorganisations of the National Health Service (NHS) and local
government have had substantial impacts upon the field. The most recent reorganisation of
the NHS in England, under the Health and Social Care Act 2012, moved responsibility for
many public health functions out of the NHS and back into local authorities for the first time
since 1974. It also saw the creation of Public Health England as an executive agency of the
Department of Health. The rationale was that local authorities would be better placed than
the NHS to address wider determinants of health and wellbeing. However, public health
teams have had to adjust to a very different environment, working alongside elected local
government officials, whose agendas may be very different. In this paper we explore the
impact of the 2012 Act upon the identity of public health professionals . We present findings
from a project exploring the impact of the Act upon the commissioning system, in which we
interviewed over 100 members of organisations including Clinical Commissioning Groups,
Local Authorities, and NHS England. Using Freidsons work on the sociology of professions as
a touchstone, we consider issues of status, autonomy, and scale for public health
professionals and their work.

Practising change in medical professionalism: using system capital to overcome conflicting

logics
Simon Moralee

This paper outlines how change can be initiated in the strongly institutionalized environment
of medical education, which is situated in the complex and contested context of the English
National Health Service (NHS). Using conceptual insights into institutional logics (Friedland &
Alford, 1991; Thornton & Ocasio, 2008) and sociological capital (Lockett et al., 2014;
Bourdieu, 1986), this article helps to establish how this particular case can further
understanding of how different institutional logics can co-exist and how change can happen
within strongly institutionalized environments. Adopting a retrospective case study
approach with key-person interviews and documentary analysis, the article centres on the
specific case of the Enhancing Engagement in Medical Leadership (EEML) project to embed
leadership and management training into the medical curriculum. This paper reveals that
contextual and environmental conditions, as well as exogenous shocks and endogenous
motivation led to this change initiative occurring. Through embedding the Medical
Leadership Competency Framework (MLCF) into contested medical curriculum space,
project members were able to make use of theirs and others social, cultural and symbolic
capital resources to form a cross-field collective capital, known as system capital. Using this,
they adopted a disposition in their practice beyond professions which I have termed as
system centrism. The implications from this paper support previous work by Goodrick and
Reay (2011) and Macdonald et al. (2013) who have argued that it is possible for competing
and incompatible logics to exist, mediated by the actions of agents in a field. This paper
builds on those previous studies to argue that the specific adoption of a system centric
approach, built on mutual system capital, allowed for co-terminus institutional logics in
medical education: one built on an education logic and the other on a service or workforce
logic.

Policy transfer of hospital accreditation: Drawing lessons from countries in Eastern

Mediterranean Region (EMR)
Wesam Mansour

Background: Hospital accreditation has transferred from high-income countries to many

low-middle income countries (LMICs). In Eastern Mediterranean Region (EMR), there is a
widespread interest in strengthening quality through accreditation. However, countries are
at different stages in adoption and implementation. Some encounter major difficulties in
adopting accreditation, while others successfully implement and sustain it. Therefore, it is
important to consider accreditation as a policy transfer issue that mobilises different
national and international actors, such as ISQua, WHO, and other donor agencies.
Objectives: This study sought to analyse the transfer of hospital accreditation to EMR
countries using theories of policy transfer. These theories can help in identifying how
stakeholders access learning from other settings, how accreditation as a new policy fits into
their local setting, and what mechanisms facilitate learning. We used policy transfer theory
to examine the interaction between national actors and networks in EMR countries, and
how international organisations influence accreditation policy transfer in the region.
Additionally, we sought to identify factors which enabled or hindered the transfer in EMR. In
this way, the study aimed to draw contextually sensitive lessons for countries seeking to
implement and sustain their own national accreditation system, and for international
organisations to help them support these countries.
Methodology: Multiple case-study design in four different countries in EMR: Egypt, Jordan,
Lebanon and Saudi Arabia. Each case was examined to understand how and why it was
successful or failed in implementing and sustaining its model of accreditation. The study
used qualitative methodsin-depth interviews and analysis of relevant documentsto
understand the accreditation policy transfer and gaps involved in each case in terms of
transferability and sustainability and how these were overcome.
Results: Hospital accreditation can be underdeveloped due to changes in government,
deficient incentives, inadequate knowledge and training, lack of legal standing, shortage of
human workforce and limited financial resources or premature end to core funding by
international donors. Nevertheless, EMR countries have established national accreditation
systems and developed their own standards based on their national context, technological
resources, and hospitals infrastructure. However, governments adopted different
techniques from those identified internationally in terms of the level of standards, scoring
system, and reporting procedures to enable hospitals to gradually comply with standards
and improving their performance with low resources. Sustainability of national accreditation
systems in EMR is a major challenge irrespective of country characteristics. It is influenced
by market size, consistency of policy support, available funding, financial incentives and the
duplication that can occur between accreditation and licensure requirements. Meanwhile,
international organisations, accreditation agencies, and government development/aid
agencies can have a substantial influence on the spread and sustainability of accreditation,
as sources of expertise and pump-priming funding.
Conclusions: Accreditation is a cluster of activities which does not transfer simply as a set of
standardised processes, but is changed as it interacts with local contexts, while at the same
time producing institutional changes locally. Implementing and sustaining an accreditation
system in a developing country requires allocated funds, political and donor commitment,
technical assistance to hospitals, and a functioning accreditation body. The results of this
study can provide the basis for a comprehensive discussion of accreditation policy to
underpin its successful implementation and sustainability.

Towards a new epistemics of incident: re-designing how we know and strategically

respond to safety incidents in the hospital setting
Mary Darking, Phil Haynes, Mr Edwards and Mr Kelly NHS Academic Health Science Network

The instruments through which safety incidents in hospitals are examined, reported and
learned from are largely qualitative. Incident reports vary in structure, content and
methodological underpinnings with root cause analysis currently the most common
method of examining and reporting safety events. However, whilst current methods offer
in-depth knowledge of individual incidents, they do not produce knowledge of how incidents
relate to one another and to the hospital setting over time. This has consequences for how
safety incidents are strategically responded to and learned from. In this research we seek to
understand the extent to which apparata for analytically reading across safety incidents can
offer new forms of insight into understanding such events relationally. In order to achieve
this we have developed a pragmatist, taxonomical coding system which we use to code
retrospective and contemporous safety incident data which is subsequently analysed using a
mixed method approach that draws on complexity theory. Qualitative coding of safety
incidents enables them to be conceputalised sociomaterially as cases that are complexly
inter-related. Fuzzy set qualitative comparative analysis (fsQCA) allows the extent to which
cases relate to one another to be examined statistically. This methodological approach
enables us to open out 3 specific dimensions of relationality to enquiry. Firstly, we analyse
incidents at an organisational level identifying the domains and facets of care that are
indicated as significant. Secondly, we consider incidents temporally and spatially, looking for
substantive patterns across the temporal routines, physical spaces and organisational
groups within the hospital setting. Lastly, we consider incidents in relation to hospital safety
teams and the processes through which they are tasked with making sense of and initiating
clinical and managerial responses to them. Our early results indicate that taxonomically
coding safety incidents produces stable knowledge that offers insight into patterns of care
failings specific to the care setting. The epistemic underpinning of this knowledge and the
processes through which it is produced differ from more classical forms. However, we argue
that the possibilities such analyses open out for enhancing understanding of safety incidents
within the hospital setting suggests new possibilities for improving care that current forms
of management, enquiry and investigation do not yet address.

Motivation Matters: A Case Study on Faecal Microbiota Transplants in English and Ontario
Hospitals
Pamela Khune

Does innovation get shepherded or stymied in publicly funded health care if it is without a
commercial sponsor to aid its diffusion? This paper reports findings from a PhD qualitative
research case study on the use/non-use of Faecal Microbiota Transplants (FMT) at English
(UK) and Ontario (Canada) hospitals. FMT is an approved non-commercial innovation (NCI)
for recurrent Clostridium difficile infections that uses human faecal matter to treat the
condition. This Realist Evaluation found that the research intensity of the hospital was not
indicative of its readiness to adopt the NCI. Rather, the mechanisms of (1) a clinical
champion, unequivocal as intrinsically motivated, nurtured (2) interdisciplinary collaboration
for the validation and implementation of the NCI. For executive and clinical decision-makers
(3) peer reviewed evidence, published in highly regarded journals, affected the perceptions
of value and riskiness of the NCI. Finally, the (4) political context affected the degree to
which institutional resources were available to evaluate and to implement NCI.

The fragmentation of China health insurance system and its reform

Binrui Zheng

Due primarily to the institutional differences and the localism with the Chinas health
system, the Chinese health insurance (HIS) has a fragmented character. Fragmentation is
best conceived as the simultaneous existence of variousoften competingregulations
in different regions and among different social classes, with resulting the differences in the
welfare standards. This degree of complexity has severely constrained the performance of
Chinese health institutions. Whether judged from an efficiency or equity standpoint, the
fragmentation problem of HIS carries many far-reaching negative effects, such as the poor
affordability problem. Other problems equal severity such as dual-track arrangements, and
difficulties associated with social pooling also have their origins in fragmentation. These
difficulties are such as to warrant the comprehensive reform of the Chinese health. Adopting
Gough et als (2004) understanding of the informal security regime (ISR) as its main
conceptual underpinning, this paper sets out to achieve a better understanding of recent
trends in the Chinese health reform. Chinese governments have adopted many different
reforms in recent years, such as integrating health insurance systems and reforming the
payment methods. The paper argues that China is adopting the right strategies to reform its
health security system, but these strategies risk being blown off course if the fragmentation
problem remains unresolved. If China can overcome this major difficulty that is blocking the
path to health insurance reform problem, the country will be in a better position to achieve
a better healthcare, which in turn will reduce the risks associated with the ISR and aid
progress towards a more comprehensive model of welfare.

Interpreting the concept of a 7-day NHS using an evaluation of 7-day access to primary
care in Greater Manchester
Damian Hodgson, Pauline Nelson, Will Whittaker, Natalie Ross, Laura Anselmi, Caroline
ODonnell, and Katy Rothwell

There are challenges to rolling out new healthcare policies, given wide variations between
local health economies. Varying factors can include finances, patient characteristics, social
and economic settings, and differences in management priorities. Devolution, and coalition
building through Sustainability and Transformation Partnerships (STPs), are only a partial
solution to this problem, as there are still divisions, even at a regional level. This paper
explores the issue of regional variation by considering one specific policy change being
implemented across Greater Manchester: 7-day access to primary healthcare services.
In Greater Manchester, the CLAHRC Greater Manchester research team evaluated the roll
out of 7 day access to primary healthcare services across seven local CCG areas. These areas
submitted their plans for the delivery of 7 day primary care access to NHS England in mid-
2015, to run throughout 2016. Despite agreed minimum standards for 7 day access,
including the number, and type, of hubs, extent of hours, and range of services provided, the
evaluation found substantial variation in the interpretation of the policy steer. In particular,
interpretation of the routine general practice not urgent care policy steer in the face of
different local conditions led to a variation in the implementation of the policy, with some
areas offering a suite of 7-day services, and others barely getting it off the ground. The
variation highlighted by the evaluation points to of a high degree of ambiguity and conflict
surrounding the policy aim (Matland, 1995) and questions around public engagement.
Evidence suggests that in some instances, the policy was not articulated clearly enough, or
understood well enough, within each area before the launch of the pilot.
How regional agencies, such as the Greater Manchester Health and Social Care Partnership,
might go about implementing new policy steers better under such conditions might begin
with a willingness and openness to tolerating variation in the piloting and rolling out of 7-
day NHS services. In addition, Matlands framework for high policy ambiguity/conflict
approaches to implementation suggests that more time may be required in piloting work for
engaging with stakeholders and communicating the aims of the policy. This would include a
focus on both improved articulation of the policy steer and also a clearer understanding
from stakeholders.