What can the Irish Healthcare system learn from health policy implementation research?

Introduction In Ireland, as is the case in many developed countries’ health systems, there has been fragmentation of healthcare delivery. The concept of integrated care is perceived to be the way forward towards the... [ view full abstract ]

Introduction

In Ireland, as is the case in many developed countries’ health systems, there has been fragmentation of healthcare delivery. The concept of integrated care is perceived to be the way forward towards the achievement of greater efficiency and value from health delivery systems through improved coordination. However, literature on implementation has revealed that effective policy implementation is difficult to achieve. This paper seeks to review lessons from health policy implementation research that can assist the Irish healthcare system in the implementation and delivery of services.

Importance and key contribution

Current Irish healthcare reform emphasises the need to integrate care more effectively in response to fragmentation both within the secondary, primary care and community care sectors (DOH 2014). The integration of healthcare systems has been promoted as a means to build a more effective and efficient healthcare system that takes a patient centred focus and better meets the needs of the population (Armitage et al 2009). This can be achieved through a set of combined processes and models (Shaw, Rosen & Rumbold 2011). This developmental paper reports on a pilot study examining the implementation of community healthcare organisations (CHOs) in Irish health care.

An earlier systematic literature review by the authors identified that stakeholder involvement was one of the facilitators to successful implementation of integrated care. The literature on implementation has highlighted that successful policy implementation demands aligned health professionals regarding health policy changes (Christian, Cristina, & Myriam,2014). This paper further emphasizes the importance of front-liners in the implementation of integrated healthcare policy especially as it relates to the ongoing implementation process of the Community Health Organisations (CHOs) in Ireland.

Policy implementation research is wide ranging but perspectives that are pertinent to this study include the bottom-up view recognising the importance of front-line staff and their discretionary decision-making, as well as flexibility that allows for adaptation to local difficulties and contextual factors (Byers 2015). It also includes understanding rules and norms of health professionals, the influence of new knowledge (Nilsen et al, 2013). The current trend in integrated healthcare implementation research focuses on professional perceptions and experiences as opposed to networks and structures (Ling et al, 2012, Evans et al., 2014, Agnieszka et al., 2014).

Theoretical base

An institution is typically bounded by a set of social, political, economic and legal contexts and its environment is characterised by the elaboration of rules and requirements to which individual organisations must conform if they are to receive acceptance and legitimacy (Vishanth & Zahir, 2009).
Institutional theory is used to explore a range of research challenges in the fields of public sector and health policy to study the impact of external forces on organisational behaviour (Vishanth & Zahir, 2009). Nilesen et al, (2013) note that institutional theory offers explanations for the difficulties with implementing research based knowledge and achieving desired changes in healthcare.

A central argument of this perspective is that the adoption and use of new practices is not solely a means of improving performance, but as much a symbolic process of achieving organisational legitimacy. It also allows for explanations of the lack of change despite political intentions. By emphasizing intra and inter-organisational processes, the institutional perspective contributes to improved understanding of factors beyond the realm of evidence, research or professional development that influences practice changes in healthcare (Nilsen et al., 2013).

Within the context, researchers are encouraged to investigate the implementation process at the coal face of practice and examine how explicit research-based knowledge is blended with implicit practice-based knowledge as health professionals translate, adapt and renegotiate research findings to make sense of them within the context of their everyday work (Nilsen et al., 2013).

Managing implementation requires deliberate engagement with the values, interests and understandings of those actors who might block or subvert policy change (Lucy, 2013). Utilising a street-level perspective; directs us to look at ‘where’ policy is implemented and explored, the practices of the managers and health professionals at street level as they attempt to put policy into action within a constrained and controlled environment (Brodkin 2011, Byers 2015).

The Strategy-as-Practice perspective adds to this body of research by examining these activities or practices at the micro-level that make up strategy in practice (Golsorkhi, Rouleau, Seidl & Vaara 2010) or in the public sector context; policy-as-practice. At the same time it also appreciates the role of the macro-level institutions in shaping these activities. Managers and health professionals are not acting in isolation but are drawing upon socially defined modes of acting that arise from the institutions to which they belong.

This paper therefore will contribute to knowledge by:

• Exploring health care professionals’ practices, perceptions and experiences in the ongoing implementation of integrated healthcare reform.
• Exploring the effect of new knowledge on the implementer’s long standing practice and how healthcare practitioners influence the implementation process.
• Proposing a sustainable framework for the implementation of integration strategy based on collaboration/coordination relationships and change management.
This paper is part of a larger study which seeks to investigate the role of practices in implementing integrated healthcare reform in Ireland.

Research question and method

The Health Services Executive (HSE – Ireland) the national body for the delivery of Health & Social Care recommends the establishment of 9 Community Healthcare Organizations (CHOs) and the associated governance and management arrangements to enable integrated community care in Ireland. The aim of this paper is to report on an initial pilot study (part of a wider study) tracking the implementation of this new reform of integrating care in CHOs as it unfolds, from the perspectives of those at the front-line, street-level: the healthcare professionals.

The question posed is:
‘How do health professional’s perceive and experience health policy implementation at the front-line?


This paper reports on this initial pilot study, which is part of a wider multiple case-study approach utilising intensive examination of the processes of planning and implementation in each of the cases (CHOs) (Yin 2013). The aim of the wider study is to build a rich picture of each case. The approach to data collection is by document analysis and semi-structured and in-depth interviews. It is important to investigate how institutional complexity is dealt with inside the organizations and how the street-level health professionals and their immediate healthcare professional line managers understand and interpret the reform itself and its effect on practices. As well as gaining some views of those senior managers and others in the wider institutional environment.

In order to test the design and the effectiveness of the research approach, pilot interviews were carried out in one of the new CHOs. Exploratory interviews (3) have begun with 2 Healthcare Professional Line Managers and 1 Senior Manager. These interviews indicate that those healthcare managers at street-level have already been integrating their services in multi-disciplinary teams (over recent years) but the implementation roadshows that have begun are informing them that there will be a curtailment of resources and that their performance metrics will be redrawn from the top.

Implications

This pilot study provides preliminary data and lays the groundwork for a larger scale study on professional perceptions and experiences. A number of preliminary themes have emerged but are at a very early stage in terms of analysis and thus may change as field work progresses. These themes will be outlined in the paper.




References

Méndez, C.A., Miranda, C., Torres, M.C. and Márquez, M. (2014). Implementing Hospital Self Management Policy in Chile: Health Professionals' Perception. Rev. Gerenc. Polit. Salud, Bogotá (Colombia), 12(27), 86-95.

Ignatowicz, A., Greenfield, G., Pappas, Y., Car, J., Majeed, A. and Harris, M. (2014) Achieving provider engagement: providers’ perceptions of implementing and delivering integrated care Qualitative Health Research, 24(12), 1711-1720.

Brodkin, E. (2011) Policy work: street-level organizations under new managerialism. Public Administration Research & Theory 21, 2: i253-i277

Byers, V. (2015) The challenges of leading change in health-care delivery from the front-line. Journal of Nursing Management. Article published online: 9 December, DOI: 10.1111/jonm.12342.

Golsorkhi, D., Rouleau, L., Seidl, D. and Vaara, E. (eds.) (2010) Cambridge Handbook of Strategy-as-Practice. Cambridge: Cambridge University Press.

Ling, T., Brereton, L., Conklin, A., Newbould, J., & Roland, M. (2012). Barriers and facilitators to integrating care: Experiences from the English Integrated Care Pilots International Journal of Integrated Care, 12, 1-12.

Lucy, G. (2013). Implementing health system change: What are the lessons from the African Health Initiative? . Health Services Research, 13(2), 1472-6963

Nilsen, P., Ståhl, C., Roback, K., & Cairney, P. (2013). Never the twain shall meet? - a comparison of implementation science and policy implementation research Implementation Science, 8(63), 1-12.

Svensson., P,Spoelstra., S,Pedersen., M and Schreven., S (2010). The excellent institution. Theory and Politics in Organization, 10(1):1-6.

Rouleau, L.( 2005). Micro-practices of strategic sensemaking and sensegiving: How middle managers interpret and sell change every day. Journal of Management Studies, 42(7) 1413-1442

Vishanth, W., K, D. Y., & Zahir, I. (2009). The diffusion and use of institutional theory: a cross-disciplinary longitudinal literature survey Journal of Information Technology, 24, 354-368

Healthcare, Implementation, Integrated care, Community Healthcare Organisations,Patient-Centred care, Health policy, Front-liners, Institutional theory,Public sector,Organisational change, organisational behaviour, health... [ view full abstract ]

Healthcare, Implementation, Integrated care, Community Healthcare Organisations,Patient-Centred care, Health policy, Front-liners, Institutional theory,Public sector,Organisational change, organisational behaviour, health professional, Health reform, street level