Bloody paperwork:Algorithmic governance and control in UK integrated health and social care settings

This article is about paperwork: the work staff in UK integrated health and social care teams did to transform small transactions of everyday care work into big data, which in turn enabled the governance of complex service arrangements. This data-driven approach to governance, algorithmic governance, raises issues of agency and transparency. We address these issues by paying close attention to how care staff articulated their own understandings and apprehensions of the process. The article draws on a study of work roles in UK integrated health and social care teams providing support and follow up for older people and people with mental health problems. Digitised tools were used for the coordination and management of these teams. Staff described how the digitised documentation of care practices produced standardised representations of their work which poorly reflected the complexity of their everyday interactions with colleagues and clients/patients. There was a double-ness to these representations: on the one hand, they were malleable and open to negotiation, on the other they produced tangible consequences hardwired into the system of governance, transforming the work of care into an object outside of itself. In order to bring out the complexities in staff’s accounts about paperwork, the article brings the Marxist analytic of alienation into conversation with Actor Network Theory (ANT) to suggest that overstating the hegemonic power of digital technologies risks itself becoming hegemonic. We advocate a nuanced and situated analysis of what digitised documentary practices consist of and what they do in different circumstances

Can we mandate partnership working? Top down meets bottom up in structural reforms in Scotland and Norway

Purpose Partnership working across health and social care is considered key to manage rising service demand whilst ensuring flexible and high-quality services. Evidence suggests that partnership working is a local concern and that wider structural context is important to sustain and direct local collaboration. “Top down” needs to create space for “bottom up” management of local contingency. Scotland and Norway have recently introduced “top down” structural reforms for mandatory partnerships. The purpose of this paper is to describe and compare these policies to consider the extent to which top-down approaches can facilitate effective partnerships that deliver on key goals. Design/methodology/approach The authors compare Scottish (2015) and Norwegian (2012) reforms against the evidence of partnership working. The authors foreground the extent to which organisation, finance and performance management create room for partnerships to work collaboratively and in new ways. Findings The two reforms are held in place by different health and social care organisation and governance arrangements. Room for manoeuvre at local levels has been jeopardised in both countries, but in different ways, mirroring existing structural challenges to partnership working. Known impact of the reforms hitherto suggests that the potential of partnerships to facilitate user-centred care may be compromised by an agenda of reducing pressure on hospital resources. Originality/value Large-scale reforms risk losing sight of user outcomes. Making room for collaboration between user and services in delivering desired outcomes at individual and local levels is an incremental way to join bottom up to top down in partnership policy, retaining the necessary flexibility and involving key constituencies along the way.publishedVersio

Morale among general practitioners:qualitative study exploring relations between partnership arrangements, personal style, and workload

OBJECTIVES: To explore general practitioners' experiences of wellbeing and distress at work, to identify their perceptions of the causes of and solutions to distress, and to draw out implications for improving morale in general practice. DESIGN: Three stage qualitative study consisting of one to one unstructured interviews, one to one guided interviews, and focus groups. SETTING: Fife, Lothian, and the Borders, South East Scotland. PARTICIPANTS: 63 general practitioner principals. RESULTS: Morale of general practitioners was explained by the complex interrelations between factors. Three key factors were identified: workload, personal style, and practice arrangements. Workload was commonly identified as a cause of low morale, but partnership arrangements were also a key mediating variable between increasing workload and external changes in general practice on the one hand and individual responses to these changes on the other. Integrated interventions at personal, partnership, and practice levels were seen to make considerable contributions to improving morale. Effective partnerships helped individuals to manage workload, but increasing workload was also seen to take away time and opportunities for practices to manage change and to build supportive and effective working environments. CONCLUSIONS: Solutions to the problem of low morale need integrated initiatives at individual, partnership, practice, and policy levels. Improving partnership arrangements is a key intervention, and rigorous action research is needed to evaluate different approaches

Hvordan praktisere brukermedvirkning uten brukeren? Organisatoriske utfordringer for brukermedvirkning i helse og omsorgstjenester i rus og psykiatrifeltet

Brukermedvirkning i behandling er en lovfestet rett i Norge. Hvordan er helsepolitiske føringer implementert i praksis? Vi diskuterte medvirkning med brukere, pårørende og tjenesteytere i rus og psykisk helsevern i en norsk kommune og samarbeidende spesialisthelsetjenester. Data ble samlet fra to ulike arenaer. I tjeneste, bruker- og pårørendespesifikke grupper diskuterte deltakerne hvordan helsepolitiske føringer og et fragmentert tjenesteapparat satte ulike aktører opp mot hverandre og reduserte medvirkningen for alle. I mindre, tverrfaglige grupper som inkluderte brukere og pårørende, kom eksempler fram om tverrfaglig praksis som en arena for felles problemløsning. Artikkelen bidrar med teori, forskningsmetoder og praksis om tjenesteutvikling på lokalplan. Det er i denne konteksten brukere, pårørende og tjenesterepresentanter kan jobbe sammen for å realisere intensjonen i sentral helsepolitikk.publishedVersio

Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units

Objectives: Various strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.Design: A qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period.Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.Results: Three themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.Conclusions: The current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality

‘Intensive care unit survivorship’ - a constructivist grounded theory of surviving critical illness

Aims & objectiveTo theorise ICU survivorship after a critical illness based on longitudinal qualitative data.BackgroundIncreasingly patients survive episodes of critical illness. However, the short and long term impact of critical illness include physical, psychological, social and economic challenges long after hospital discharge. An appreciation is emerging that care needs to extend beyond critical illness to enable patients to reclaim their lives post-discharge with the term ‘Survivorship’ being increasingly used in this context. What constitutes critical illness survivorship has, to date, not been theoretically explored.DesignLongitudinal-qualitative and constructivist Grounded Theory. Interviews (n = 46) with 17 participants were conducted at four time points: (1) before discharge from hospital, (2) 4-6 weeks post-discharge, (3) 6 months and (4) 12 months post-discharge across two adult intensive care setting.MethodIndividual face-to-face interviews. Data analysis followed the principles of Charmaz's Constructivist Grounded Theory. ‘ICU survivorship’ emerged as the core category and was theorised using concepts such as Status Passages, Liminality and Temporality to understand the various transitions participants made post-critical illness.FindingsIntensive care survivorship describes the unscheduled status passage of falling critically ill and being taken to the threshold of life and the journey to a life post-critical illness. Surviving critical illness goes beyond recovery; surviving means ‘moving on’ to life post-critical illness. ‘Moving on’ incorporates a re-definition of self that incorporates any lingering intensive care legacies and being in control of one's life again.Relevance to clinical practiceFor healthcare professionals and policy makers it is important to realise that recovery and transitioning through to survivorship happens within an individual's time frame, not a schedule imposed by the healthcare system. Currently there are no care pathways or policies in place for critical illness survivors that would support ICU survivors and their families in the transitions to survivorship

A longitudinal qualitative exploration of healthcare and informal support needs among survivors of critical illness: the RELINQUISH protocol

Introduction and background: Survival following critical illness is associated with a significant burden of physical, emotional and psychosocial morbidity. Recovery can be protracted and incomplete, with important and sustained effects upon everyday life, including family life, social participation and return to work. In stark contrast with other critically ill patient groups (eg, those following cardiothoracic surgery), there are comparatively few interventional studies of rehabilitation among the general intensive care unit patient population. This paper outlines the protocol for a sub study of the RECOVER study: a randomised controlled trial evaluating a complex intervention of enhanced ward-based rehabilitation for patients following discharge from intensive care. Methods and analysis: The RELINQUISH study is a nested longitudinal, qualitative study of family support and perceived healthcare needs among RECOVER participants at key stages of the recovery process and at up to 1 year following hospital discharge. Its central premise is that recovery is a dynamic process wherein patients’ needs evolve over time. RELINQUISH is novel in that we will incorporate two parallel strategies into our data analysis: (1) a pragmatic health services-oriented approach, using an a priori analytical construct, the ‘Timing it Right’ framework and (2) a constructivist grounded theory approach which allows the emergence of new themes and theoretical understandings from the data. We will subsequently use Qualitative Health Needs Assessment methodology to inform the development of timely and responsive healthcare interventionsthroughout the recovery process.Ethics and dissemination: The protocol has been approved by the Lothian Research Ethics Committee (protocol number HSRU011). The study has been added to the UK Clinical Research Network Database(study ID. 9986). The authors will disseminate the findings in peer reviewed publications and to relevant critical care stakeholder groups