The interface between transactional and relational orientation in small service firm's marketing behaviour

This paper presents and discusses findings of a cross-country study of small service firm marketing behavior. These findings demonstrate that small service firms are flexible in the marketing approaches that they adopt. They reveal that such firms are transactional and relational orientated in their marketing activities and that for growing firms, marketing activities are used to create short-term transactions and form relations with key stakeholders. This finding implies that transactional and relationship marketing should be regarded as complementary. The findings presented also demonstrate that the marketing approach selected by participating small firms is determined by a range of customer characteristics of which repeat business is only one. An integrated framework containing elements of transactional and relational approaches is proposed as an appropriate way of describing the marketing behaviours of investigated firms

Leading and managing collaborative practice: the research : ESRC Seminar 3 Proceedings

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Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Front‐line perspectives on ‘joined‐up’ working relationships: a qualitative study of social prescribing in the west of Scotland

Cross-sector collaboration has been promoted by government policies in the United Kingdom and many western welfare states for decades. Literature on joint working has focused predominantly on the strategic level, neglecting the role of individual practitioners in putting ‘joined-up working’ into practice. This paper takes the case of ‘social prescribing’ in the West of Scotland as an instance of joined-up working, in which primary healthcare professionals are encouraged to refer patients to non-medical sources of support in the third sector. This study draws on social capital theory to analyse the quality of the relationships between primary healthcare professionals and third sector practitioners. Eighteen health professionals and 15 representatives of third sector organisations participated in a qualitative interview study. Significant barriers to collaborative working were evident. The two stakeholder groups expressed different understandings of health, with few primary healthcare professionals considering non-medical sources of support to be useful or relevant. Health professionals were mistrustful of unknown third sector organisations, and concerned about their accountability for referrals that were not successful or positive for the patient. Third sector practitioners sought to build trust through face-to-face interactions with health professionals. However, primary healthcare professionals and third sector practitioners were not connected in effective networks. We highlight the on-going imbalance of power between primary healthcare professionals and third sector organisations. Strategic collaborations should be complemented by efforts to build shared understandings, trust and connections between the diverse frontline workers whose mutual co-operation is necessary to achieve effective joined-up working

Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level. Objectives To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

What makes a looked after child happy and unhappy?

What is good for a looked after child is usually decided by adults with the child’s voice often peripheral. One way to make the child central to decision-making is to ask them what makes them happy or unhappy. In doing this, the definition of happiness has to be neither a description of what has gone well in life nor an immediate state of mind, but should encompass the Aristotelian concept of eudaimonia. This is often translated as happiness but also incorporates notions of well-being and flourishing. The study reported here was undertaken as part of a children’s health needs assessment in an English local authority. It sought to understand why looked after children experience such high levels of poor mental health and make growing demands on therapeutic services. The proportion of young people displaying above average scores on validated measures, such as the Strengths and Difficulties Questionnaire (SDQ), is growing each year. The aim was to find out what looked after children say makes them happy and unhappy and what they see as likely to increase their well-being, and to compare their suggestions with those of the professionals and carers involved in their lives. Focus groups with children and professionals then discussed the same question, with the professionals also examining their understanding of SDQ results and their relevance to practice. The study found significant differences between the views of the children and professionals in both the range and emphasis of what is seen as important. Moreover, these adult assumptions were rarely tested by meaningful discussions with young people when key decisions were made; indeed, these seemed to be made about rather than with the children. In addition, the SDQ was not widely used by professionals to assess children’s emotional health and well-being needs. The study concluded that discussions about happiness can usefully support holistic understandings of looked after children’s experiences and aid planning and practice development

The Neuro-Symbolic Concept Learner: Interpreting Scenes, Words, and Sentences From Natural Supervision

We propose the Neuro-Symbolic Concept Learner (NS-CL), a model that learns visual concepts, words, and semantic parsing of sentences without explicit supervision on any of them; instead, our model learns by simply looking at images and reading paired questions and answers. Our model builds an object-based scene representation and translates sentences into executable, symbolic programs. To bridge the learning of two modules, we use a neuro-symbolic reasoning module that executes these programs on the latent scene representation. Analogical to human concept learning, the perception module learns visual concepts based on the language description of the object being referred to. Meanwhile, the learned visual concepts facilitate learning new words and parsing new sentences. We use curriculum learning to guide the searching over the large compositional space of images and language. Extensive experiments demonstrate the accuracy and efficiency of our model on learning visual concepts, word representations, and semantic parsing of sentences. Further, our method allows easy generalization to new object attributes, compositions, language concepts, scenes and questions, and even new program domains. It also empowers applications including visual question answering and bidirectional image-text retrieval.Comment: ICLR 2019 (Oral). Project page: http://nscl.csail.mit.edu

Addressing Childhood Adversity and Social Determinants inPediatric Primary Care:Recommendations for New Hampshire

Research has clearly demonstrated the significant short- and long-term impacts of adverse childhood experiences (ACEs) and the social determinants of health (SDOH) on child health and well-being.1 Identifying and addressing ACEs and SDOH will require a coordinated and systems-based approach. Pediatric primary care* plays a critical role in this system, and there is a growing emphasis on these issues that may be impacting a family. As awareness of ACEs and SDOH grows, so too does the response effort within the State of New Hampshire. Efforts to address ACEs and the SDOH have been initiated by a variety of stakeholders, including non-profit organizations, community-based providers, and school districts. In late 2017, the Endowment for Health and SPARK NH funded the NH Pediatric Improvement Partnership (NHPIP) to develop a set of recommendations to address identifying and responding to ACEs and SDOH in NH primary care settings caring for children. Methods included conducting a review of literature and Key Informant Interviews (KII). Themes from these were identified and the findings are summarized in this report