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

Adapting structuration theory to understand the role of reflexivity: Problematization, clinical audit and information systems

This paper is an exploratory account of the further development and application of a hybrid framework, StructurANTion, that is based on Structuration Theory and Actor Network Theory (ANT). The use of social theories in general and their use in information systems (IS) research in particular is explored leading to the use of the framework to examine the concept of what are termed humanchine networks in the context of clinical audit, within a healthcare Primary Care Trust (PCT). A particular focus is on the manner in which information systems-based reflexivity contributes to both entrenching a networks’ structurated order as well as contributing to its emancipatory change. The case study compares clinic-centric and patientcentric audit and seeks to further extend the understanding of the role of information and information systems within structurated humanchine activity systems. Conclusions indicate that the use of more socially informed IS methods and approaches can incorporate more emancipatory ideals and lead to greater adoption and usage of more relevant and useful clinical information systems and practices

Building sustainable hospitals: A resource interaction perspective

In response to a growing influence of patients, higher specialisation, technological advancement and the need to provide care services more efficiently, the issue of sustainability in healthcare has gained prominence. The purpose of this paper is to investigate how the social and economic sustainability of healthcare are dependent on interconnecting resources across organisational borders and in different settings over time. Adopting a product development process perspective, the paper explores the gap between a planned healthcare facility and how it actually came to be used, through a longitudinal case study of the Skandion clinic, a small, highly specialised, hospital in Sweden. The findings suggests that integration of healthcare resources over time is central to achieve social and economic sustainability goals. The results hereby contend the prevailing view of hospitals as independent organisational units and highlights the need for more holistic analyses of sustainability in healthcare. Analyses which take into account the complex interdependencies stretching across networks of interconnected facilities and organisational units

Going beyond your personal learning network, using recommendations and trust through a multimedia question-answering service for decision-support: A case study in the healthcare.

Social learning networks enable the sharing, transfer and enhancement of knowledge in the workplace that builds the ground to exchange informal learning practices. In this work, three healthcare networks are studied in order to understand how to enable the building, maintaining and activation of new contacts at work and the exchange of knowledge between them. By paying close attention to the needs of the practitioners, we aimed to understand how personal and social learning could be supported by technological services exploiting social networks and the respective traces reflected in the semantics. This paper presents a case study reporting on the results of two co-design sessions and elicits requirements showing the importance of scaffolding strategies in personal and shared learning networks. Besides, the significance of these strategies to aggregate trust among peers when sharing resources and decision-support when exchanging questions and answers. The outcome is a set of design criteria to be used for further technical development for a social semantic question and answer tool. We conclude with the lessons learned and future work

The Health and Wellbeing of Homeless People: Complexities around the Provision of Primary Healthcare in New Zealand

Homelessness is a pressing social issue, and people who are homeless, in particular those who sleep rough, often experience a confluence of physical and mental health issues. Health problems experienced by homeless people can be more severe than those experienced by domiciled people. Such problems can contribute to homelessness, and be exacerbated by homelessness. Previous research has found that for various reasons, primary healthcare services can be inaccessible for homeless populations. More recent research explores the growing availability of accessible, non-threatening health services targeting homeless people, with humanistic approaches to care. This thesis draws on a case study of an NGO clinic providing population-based primary healthcare to homeless and low-income people. The case study is informed by the perspectives of two groups of participants; homeless clinic patients and clinic staff. Ten semi-structured interviews were conducted with homeless clients, and six semi-structured interviews were undertaken with clinic personnel. Social representations theory informs the interpretation, analysis and discussion of the participants' conceptualisations of health and wellbeing, illness and disease, homelessness, health services and the NGO clinic. Social representations from both participant groups (micro perspectives) inform shared social representations (macro perspectives) of the NGO clinic. This determines whether participants conceptualise the clinic as an 'ideal' health service for homeless people. NGO clinic staff responses reveal that clinic staff have a personal and professional ethos to work with people in need and those that may have been stigmatised from society. This shared ethos has shaped the development of the NGO clinic, into its current structure of a holistic, population based primary healthcare for homeless people integrated within a wider social service structure. In this setting, relationships are developed between practitioners and homeless clients to ensure homeless patients healthcare needs are met. Also, practical needs are met as the clinic provides low-cost healthcare to homeless people within the context of an umbrella organisation that provides other much-needed social services. Collaboration is an important component to the efficacy of the NGO clinic, and meeting patient needs. However, clinic staff note that there are many dilemmas in providing healthcare to homeless people, and they can struggle to provide the service according to their vision, due to funding constraints. Nonetheless, NGO clinic personnel are committed to working with their patients, and find their jobs rewarding. The responses from homeless clinic patients brought to mind a military metaphor, which was utilised to anchor the experiences of homeless people in a familiar concept - the military. Each homeless client that was interviewed at the NGO clinic is written about in the form of a health biography, which summarises current health issues, health histories, health related practices and conceptualisations of health. The severity of three major health issues experienced by the participants - addictions, mental health issues and foot problems - are then explored in terms of detailed perspectives from homeless participants, and clinic personnel conceptualisations of those particular health issues. Social networks are discussed as important to homeless people's health and wellbeing, particularly through resource and information sharing. The clinic setting is conceptualised by homeless participants as a caring, welcoming environment; which contrasts with some negative experiences reported by homeless participants in other health service settings. This thesis explores the NGO clinic as a unique model for a health service that meets the various healthcare needs of homeless people. There is a need for more recognition from government organisations and policy makers of the impoverished life situations that many homeless people find themselves in - often without minimum standards of living, which jeopardises their ability to take care of their health. Appropriate health services need to be accessible to homeless people, in order for healthcare needs to be met

Telehealth and information society: a critical study of emerging concepts in policy and practice

This thesis explores a number of interrelated factors that influence the development of telehealth. Telehealth refers to health-related services that can be provided in electronic form over various telecommunications networks, including applications beyond clinical settings and reaching out to communities and homes. As such this study encompass different disciplines and draws not only on the medical tradition but also on information systems, social theory and ideas of information society. The study is based on the fundamental claim that technology does not follow a pre-determinate path but is shaped by people, who in turn are constrained by historical conditions and current structures. The research takes into consideration a number of such defining structures, including the organisation of healthcare in Britain, the health policy process, strategies for the employment of information and communications technologies (ICTs), conflicting ethical traditions and their manifestations in evaluation processes, and visions of an information society. The theoretical position and research approach is informed by critical theory. Thus the work focuses on the different, often conflicting, interests of varied stakeholders. It also unveils factors constraining social aims to which telehealth could aspire, e.g. reducing social exclusion and supporting empowerment of patients and citizens. Insights into these concepts and their practical manifestations are explored through a set of linked case studies, which investigate a variety of telehealth projects and initiatives in the London Borough of Lewisham. The thesis' contribution is twofold - practical and theoretical. The practical contribution is aimed at those who work in and study telehealth, offering a new approach and focus that is not substantially found in other telehealth studies. In this the thesis makes a contribution to the ongoing debates about telehealth's potential implications for the healthcare process. The theoretical contribution is found in the thesis' re-affirmation of the applicability of critical theory to the development of ICT-based social and organisational innovations, re-conceptualised in the light of post-modern and information society theories

A Case-Control Study to Identify Community Venues Associated with Genetically-clustered, Multidrug-resistant Tuberculosis Disease in Lima, Peru

Background: The majority of tuberculosis transmission occurs in community settings. Our primary aim in this study was to assess the association between exposure to community venues and multidrug-resistant (MDR) tuberculosis. Our secondary aim was to describe the social networks of MDR tuberculosis cases and controls. / Methods: We recruited laboratory-confirmed MDR tuberculosis cases and community controls that were matched on age and sex. Whole-genome sequencing was used to identify genetically clustered cases. Venue tracing interviews (nonblinded) were conducted to enumerate community venues frequented by participants. Logistic regression was used to assess the association between MDR tuberculosis and person-time spent in community venues. A location-based social network was constructed, with respondents connected if they reported frequenting the same venue, and an exponential random graph model (ERGM) was fitted to model the network. / Results: We enrolled 59 cases and 65 controls. Participants reported 729 unique venues. The mean number of venues reported was similar in both groups (P = .92). Person-time in healthcare venues (adjusted odds ratio [aOR] = 1.67, P = .01), schools (aOR = 1.53, P < .01), and transportation venues (aOR = 1.25, P = .03) was associated with MDR tuberculosis. Healthcare venues, markets, cinemas, and transportation venues were commonly shared among clustered cases. The ERGM indicated significant community segregation between cases and controls. Case networks were more densely connected. / Conclusions: Exposure to healthcare venues, schools, and transportation venues was associated with MDR tuberculosis. Intervention across the segregated network of case venues may be necessary to effectively stem transmission

Machines and machinations: The integrated care record service in the UK national health service

This paper examines the use of Actor Network Theory (ANT) as a lens to get a better understanding of the implementation of the Integrated Care Record Service (ICRS) in the UK National Health Service (NHS). Actor Network Theory has been deployed in various environments to achieve a better understanding of the roles of not only the humans but also the artifacts that constitute, in this case, healthcare networks of services and organisations. The theory is used as a means of supporting real world interventions, providing a richer understanding of complexities involved and thereby helps management to make better decisions. This study also explores Latour’s concept of machines as machinations, whose role is to translate other actors into the network. We propose ICRS as a fruitful empirical context for the use of ANT to support decision making for actors in health care provision. Actor Network Theory (ANT) is well-suited for use in the socio-technical evaluation of IS into the ICRS project because this approach treats human and non-human actors symmetrically. This approach facilitates a more thorough examination of the ways in which information technology is enabled or restricted in social processes

Frontline 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 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