Organising Care in a Time of Covid-19: Implications for Leadership, Governance and Policy

 

1.     Intra-Crisis Policy Transfer: the case of Covid 19 in the UK

 

Martin Powell and Sophie King-Hill, University of Birmingham, UK

Learning from abroad and policy transfer feature in the literature on learning (eg Bennett and Howlett 1992; Vagionaki and Trein 2019) and in health care (eg Klein 1997; Ettelt et al 2012), but it focuses on 'normal' rather than crisis policy making. This chapter brings together the literatures on learning and policy transfer with material on crisis learning in order to assess policy transfer in the Covid 19 Pandemic in the UK.  The leading authors in the field of policy transfer, Dolowitz and Marsh (1996) suggested a series of questions that might be addressed: Who transfers policy? Why engage in policy transfer? What is transferred? Are there different degrees of transfer? From where are lessons drawn? What factors constrain policy transfer? They later added a further question about how the process of policy transfer related to policy "success" or "failure." (Dolowitz and Marsh 2000; cf Marsh and McConnell 2009)). However, although their titles stress 'learning' and 'lessons' (eg 'Who learns what from whom' (Dolowitz and Marsh 1996) and 'Learning from abroad' (Dolowitz and Marsh 2000)), the literature arguably say little about learning (eg Ingold and Monaghan 2016). The policy transfer literature focuses on 'normal' times, but there is little on policy transfer in a crisis, with its constituent elements of threat, uncertainty, and urgency. Conversely, it is broadly argued that lesson-drawing is one of the most underdeveloped aspects of crisis management.  The literature distinguishes learning across crises and learning within a crisis, or inter-crisis and inter-crisis management, and between 'routine' and 'non-routine' or 'less routine' crises (eg Moynihan 2008, 2009).

While there is some literature on inter-crisis learning from Pandemics (eg Stark 2018), the material on intra-learning during Pandemics is limited. For example, Baekkeskov and Robin (2014) claim that 'pandemic response is unique' because it was ruled by bureaucratized experts rather than by elected politicians. They argue that while natural disaster responses appear to follow a political logic, national pandemic vaccination policies follow a bureaucratic logic. However, pandemic vaccination policies diverge significantly between countries because expert judgments differ significantly. Baekkeskov (2016) focuses on the different response policies in the Netherlands and Denmark to the 2009 H1N1 'swine' influenza pandemic. The main aims explore how the main elements of learning, particularly cross-national lesson-drawing and policy transfer play out in the Covid 19 crisis. The main research questions are drawn from Dolowitz and Marsh (1996, 2000) framework (above). However, it addresses them with respect to the crisis and learning literatures. From the crisis perspective, how do threat, uncertainty, and urgency relate to policy transfer in a non-routine and intra-crisis situation? From the learning perspective, to what extent did the UK look to learn from abroad?; where did the UK look, and why?; and what did the UK learn? The material is primarily drawn from documents such as the Minutes of the scientific advisory bodies (eg SPI; NERVTAG), and associated scientific published articles (eg Lancet), Hansard Debates, media sources, and (possibly) interviews, and analysed by Interpretative Content Analysis.

 

2.     Population health management in the NHS: what can we learn from covid-19?

 

Kath Checkland, University of Manchester, UK

The NHS Long Term Plan (NHS England 2019) sets out the agenda for NHS services in England for the next decade. One of the key strands of the Plan is a move towards what is called 'Population Health Management'. This approach is briefly defined as:  [the use of] predictive prevention (linked to new opportunities for tailored screening, case finding and early diagnosis) to better support people to stay healthy and avoid illness complications (NHS England 2019 p12). Later in the document it is explained that such an approach involves the active identification of people at risk using digital tools and large data sets, and the provision of care of some kind to prevent future health problems. This approach is lauded as being 'proactive' in contrast to previous 'reactive' care. The evidence underpinning the introduction of such an approach is not described.

The covid-19 crisis provides us with an opportunity to interrogate the population health management approach in more depth, and to consider critically what it might offer, what the problems might be and what this means for the post-covid organisation of the NHS. Early in the covid-19 pandemic it was announced that in the UK a cohort of 'clinically extremely vulnerable' patients would be identified using digital tools and singled out for special care to prevent them contracting the virus. This process was called 'shielding' and it represents an example of population health management. A cohort of people have been actively identified using digital tools, and care has been provided to prevent future health problems. In this paper the 'shielding' scheme will be explored and critiqued using three theoretical lenses. Firstly, it will be considered as an example of categorisation (Bowker and Star 2000). Who is in, who is out and the basis of those decisions will be considered, and the implications addressed, including the uncertainties surrounding the classification schema and the political factors at work. Secondly, it will be considered as an example of the construction of risk (Johnson and Covello 2012). Within the policy discourse around shielding, reducing the death rate from covid-19 is presented as a simple matter of identifying risk-bearing individuals. But risk is socially and culturally constructed (Adams 2001), and biomedical risk is only one type of risk which might be considered (Adam 2011). Moreover, the construction of the category of 'high risk' is neither transparent nor straightforward.  Finally, the paper will explore population health management as a framing device which highlights particular causes of disease and distress and obscures others (Jones and Exworthy 2015). The experience of GPs in the UK in operationalising the shielding policy will be explored through these three lenses to bring to the surface the inherent contradictions and unexamined assumptions which underpin the rhetoric. Comparisons will made with a more traditional public health approach which takes account of the social determinants of health alongside biomedical and individually focused issues (Hall et al. 2018). The implications for the post-covid organisation of the health and care system will be discussed. 

 

3.      COVID-19 and primary care service delivery

 

Judith Smith, Emily Burn University of Birmingham, UK

Becks Fisher, Health Foundation, UK

Louise Locock, University of Aberdeen, UK

 

The COVID19 pandemic has led to a wholesale re-ordering of primary care service delivery both in the UK and other countries. Virtually overnight, practices were closed and consultations moved to telephone calls or online interactions wherever possible. Service changes which have been the source of protracted debate and which would ordinarily have taken years to implement have become normal practice. At the same time, other challenges and changes have included the development of 'hot hubs' for primary care across cities or districts, and the addition of new staff and roles into large teams (including formerly retired staff, part-time staff working full-time and extra hours, clinical academics, volunteers).

 

While primary care was braced for a wave of COVID19-related workload, as the pandemic evolved a growing concern emerged that patients who need to seek help have not done so, and that a backlog of ill health may be building in the community. Primary care staff are now facing another challenge as the consequences of the lockdown start to surface. In this chapter, we will firstly describe the NHS in England primary care policy response (informed by content from weekly NHSE letter to primary care, NHSE webinar content and other policy documents).  We will locate this in a wider UK and international context as appropriate.  We will also draw on co-author Becks Fisher's frontline experience as a GP to describe how existing primary care organisations in one locality worked to create a new service. We will then present findings from an ongoing empirical study supported by the Health Foundation to capture narratives from a sample of GPs, practice managers and community nurses in England, Wales and Scotland about their experiences of and responses to this unusual and shifting situation. This will include analysis of contemporary blogs and reflective articles, as well as longitudinal data captured in self-recordings, written contributions and short online interviews. This rich qualitative analysis will be complemented by analysis of national data from NHS Digital, used to describe trends in consultation numbers and types. The chapter will conclude by discussing the ways in which primary health care professionals' roles may be changing as new forms of service provision emerge in the UK and overseas in response to the Covid-19 crisis, and considering how far such changes may be sustained, or be appropriate, for the longer term.  We anticipate that policy makers will consider there to be many positive features of the shift to more virtual service provision in primary care, as well as stresses and challenges. We will examine the implications for GPs' and their teams' recovery and support.

 

4.     Remote by default: a case study of disruptive technology in primary care

 

Trisha Greenhalgh, Alex Rushforth, Sara Shaw, Catherine Pope, Chrysanthi Papoutsi, Joseph Wherton, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK

 

As a result of the Covid-19 pandemic, patients can no longer walk into a GP surgery and ask to be seen. They must apply online, phone the surgery or contact NHS111. Depending on local triage pathways, they may then get a call-back (phone or video) from a clinician, or a face-to-face appointment, possibly in a 'hot hub'.  This shift from in-person to remote-by-default consulting is the fastest and most extensive scale-up of a radical service innovation since the NHS was established in 1948. Clinicians are faced with a triple novelty: a new disease (uncertain, serious, contagious), a new way of interacting with patients (phone, video) and major changes to workflows and clinical pathways. The changes to what used to be the family doctor service are radical, frightening and difficult. They cut to the core of what it is to care and be cared for, and what 'good' and 'excellent' health services look and feel like.

Much is at stake. Lives depend on getting the right patients to hospital at the right time to ensure benefit from critical care without overwhelming the hospital with referrals. This requires accurate identification of cases for referral and monitoring of those with moderate disease - often through the medium of a new or repurposed technology. Success of such new models of care is not just about the functionality of technologies but also about their clinical safety, how we make them work, and the extent to which NHS infrastructure can accommodate them quickly enough. We know from health systems research that disruptive technological innovation, especially in heavily institutionalised environments, is complex, uncertain, challenging and risky. We are currently undertaking a rapid programme of research funded by the ESRC's COVID response fund, to explore the clinical, technical, organisational and professional challenges of the shift to remote-by-default.  This chapter will provide empirical detail of the case study plus a scholarly analysis that draws on the theoretical literature on disruptive innovation at pace and scale.

 

 

5.     Using Social and Behavioural Science to Respond to COVID-19 Pandemic in Tanzania

 

Ramadhani Marijani, University of Dodoma, Tanzania

 

Since its outbreak in December 2019 in Wuhan City China, the Coronavirus (COVID-19) pandemic is impacting on the health and socioeconomic status of the entire humanity. After the World Health Organization (WHO) declared COVID-19 a global pandemic, there have been more than 4.5 million people confirmed cases globally as of May 11th 2020 claiming more than 283,526 deaths and the number keeps on increasing. Sadly, the pandemic continues bursting across the world's most economically fragile and politically vulnerable continent-Africa.

 

Effective and sustainable management of the pandemics calls for global solidarity and partnership because it is essential to end the spread of the virus and save lives, but most equally important is to avoid the perennial negative effects on social stability and security, especially in developing countries (Lun et al., 2020:1; Anderson et al., 2020).  Relatedly, various stakeholders including national governments and international organizations respond differently with the view of containing the disease. For example, while the World Health Organization (WHO) renders global support through coordination and technical guidance (WHO, 2020), the World Bank, the European Union and other bilateral organizations are focusing on providing financial assistances (Bacha, 2020). Socially, the response has led to a massive global public health campaign to slow the spread of the virus by increasing hand washing, reducing face touching, wearing masks in public and physical distancing. Hitherto, while efforts to develop pharmaceutical interventions for COVID-19 are under way, the social and behavioural sciences can provide valuable insights for managing the pandemic and its impacts (Van Bavel,et al., 2020). 

 

It is from the foregoing context, that the health care sector is attracting the attention of social and behavioural science researchers and scholars (Van Roekel, 2019; Nagtegaal, et al., 2019; Tummers,2019; Crupi, et al., 2018; SonneNørgaard, 2018; Thaler and Sunstein, 2008). Public administration scholars are not an exceptional in this endeavor. Behavioral Public Administration is believed to address the limit of rationality by reducing biases in human behaviors (StraBheim, 2020; Lindblom, 1959; Simon, 1957; Laswell, 1951). Central to the BPA philosophy is that, people should not be drafted to act and behave in a certain ways but rather encouraged to act in ways that are better for them to stop poor habits and induce desired behavior among non-compliant majority (John, et al., 2020).  Given the rapidly developing situation in Africa and Tanzania in particular, we intend to conduct a rapid narrative review of how Tanzania government responds to COVID-19 pandemic, and offers policy and practical implications from Behavioral Public Administration perspectives. Our intention is not to replace the intensive medical and public health interventions, but rather to provide evidence on the behavioral side of those plans and support leadership in improving those mitigations interventions.

 

 

6.     Professionalism in a pandemic: shifting perceptions of nursing through social media

 

Charlotte Croft and Trishna Uttamlal, University of Warwick, UK

 

This chapter sets out to explore how models of professionalism have been influenced by the COVID-19 pandemic. Specifically, we consider how nurses have harnessed social media platforms to change widely-held public perceptions about their profession and enhance their potential for future organizational influence. Within global health systems nurses are one of the largest professional groups, and a key resource in the ongoing drive for high quality care, cost improvements and service innovation. Yet nurses have struggled to successfully leverage political or organizational capital beyond their professional jurisdiction. Existing research relates this to a perpetuation of historic professional stereotypes, undermining nurses' potential organizational influence. However, the COVID-19 pandemic has brought the important, yet previously under-recognised, role of nurses to the forefront of public consciousness, reflected through increased media interest. Further to this, nurses across the world have themselves used social media to promote the reality of their highly skilled modern roles as part of the pandemic response, to an unusually engaged public. We, therefore, ask: how has nurses' expressions of their profession through social media changed in response to the COVID-19 pandemic, and how does that influence our understandings of changing models of professionalism? 

 

We draw on findings from a research project which was ongoing at the outset of the global pandemic, analysing over 600 social media blogs by nurses to understand how they communicate their profession to others. As COVID-19 progressed, we noted changes in the way nurses attempted to explain the complexities of their many and varied clinical skills, increased the frequency of posting pictures of themselves in uniform, and agentically positioned themselves as a key resource in the pandemic response. We subsequently engaged in additional data collection of over 600 nurses' social media blogs and posts in 'real time', to gain insight into a professional group's use of social media before, during, and potentially after, a time of crisis. Through comparative analysis of over 1200 articles of social media content, we identified three key areas in which nurses' communication has changed: past, present and future professional identity; professional work; and professional leadership. We propose the COVID-19 pandemic has the potential to influence models of professionalism, as groups which have not traditionally been at the forefront of public consciousness with regard to health system leadership, now take centre stage through social media. We suggest the pandemic acts as a transitory, formative space through which such professional groups are able to shift public perceptions about their identity, work and potential leadership, leveraging increased influence over more powerful organizational and political actors. We explore the potential implications of shifting models of professionalism, and set out a research agenda to further enhance understandings of how under-represented professional groups may communicate, perpetuate or change perceptions of their profession through agentic use of social media platforms.

 

7.     Coordinating major system change in Colombia's health services in response to COVID-19

 

Simon Turner and Natalia Niño, University of los Andes, Bogotá, Colombia

 

Coronavirus (COVID-19) is posing a major and unprecedented challenge to health service planning and delivery across health systems internationally (Wang et al. 2020). Early evidence from Asian economies (Hong Kong, Singapore, and Japan) coping with COVID-19 suggests that "integration of services in the health system and across other sectors amplifies the ability to absorb and adapt to shock" (Legido-Quigley et al. 2020, p.849). However, local evidence is needed in order to contextualize and implement potential lessons for responding to COVID-19 in relation to other health systems.

 

The changes required by health systems to address the challenges posed by COVID-19 will be analysed using a social science concept, "major system change", that the lead author has used to examine other forms of service-wide change (e.g. stroke service centralization) (Turner et al. 2016). Major system change in health care involves coordinated change across multiple organizations, including providers and purchasers of services, across a metropolitan area or region with the aim of improving services across an entire geographical area (Best et al. 2012). There is an emerging literature on barriers and enablers of change involving multiple organizations, some of which have been distilled into a framework of ´simple rules´ for guiding improvement work (Best et al. 2012; Turner et al. 2016). These include involving stakeholders inside and outside the health service, combining top-down and bottom-up leadership, creating feedback loops, and learning from history or past experiences. However, little is known about how navigating major system change is influenced by a context of 'crisis' decision-making, characterized by time pressure, complexity and uncertainty (t'Hart et al. 1993), and constraints on the evidence base for, and available resources to, implement change.

 

This contribution will explore major system change in the context of a national qualitative study, funded by Colombia's Ministry of Science, Technology and Innovation, of the response to COVID-19 in Colombia, an upper middle-income country in Latin America. Colombia faces particular challenges in coordinating its response to system-wide problems like COVID-19. While the need for multi-disciplinary and multi-sectoral care is recognised (Law 1438/2011), there remains a lack of system leadership and coordination (Rodríguez-Villamizar et al. 2016, 2017). Specific organizational problems that need to be overcome to improve integration are (a) improving the capacity of specialist services to meet demand from critically ill and other types of patient affected by COVID-19 and (b) coordinating a variety of individual health service organizations and municipalities in the planning and delivery of services at local and national level. Thus, enabling integration to create the 'adaptive capacity' (Legido-Quigley et al. 2020) of suggested importance to Asian countries' response to COVID-19 may be particularly challenging and will require active intervention. This contribution will draw on findings from a qualitative study of responses to COVID-19 at the local health level within Colombia. Key themes being explored by the study include how different professions understand and participate in change processes; organizational processes including orientations toward collaboration with other organizations both within and beyond the health service in responding to COVID-19; and how the regulation and culture of the health system locally and nationally shapes the approach to, and implementation, of major system change in relation to COVID-19. The contribution will appraise the relevance of the concept of major system change in a context of 'crisis' decision-making and contribute to international lessons on improving health systems' capacity to respond to COVID-19 and future pandemics.

 

 

8.     Dancing with a Virus: Finding new Rhythms of Organizing and Caring in Dutch Hospitals

 

Iris Wallenburg, Bert de Graaff & Roland Bal, Erasmus University Rotterdam, Netherlands

 

From early March 2020, hospitals in the Netherlands have faced an inflow of severely ill patients infected with SARS-CoV-2. The unfolding political and organizational response ensued a yet unknown organizational order imbued with professional and organizational uncertainties, ranging from a loss of the clinical gaze-i.e. physicians and nurses being confronted with an unknown clinical picture who couldn't rely on their clinical (tacit) knowledge and routines anymore-to scarcity of personal protective equipment and uncertainty about the financial consequences of reprofiling and repurposing existing services (Bal, de Graaff et al. 2020). Hospitals quickly turned into crisis-organizations, developing new organizational routines to keep up with the demand surge of Covid-patients-whilst (at least temporarily) letting go of regular health services as well as of 'old' quality standards, routines, professional values and institutional arrangements.

 

In this paper, we study how hospitals in the Netherlands engage in organizing and delivering care in times of Covid-19, in particular how they work with the different temporal orders of the (anticipated) crisis and the emergent organizational responses. Within the organizing literature, time and temporal structures are depicted as processes that give rhythm and form and hence stability to everyday work practices (e.g. Orlikowski and Yates 2002). Disruption of these normal temporal orders requires synchronization and repair work, aligning different rhythms of work (Henke 1999, Bruyninckx 2017). In case of the Covid-19 outbreak, however, disruption becomes normal as the crisis unfolds and the virus develops its own rhythm in being more or less present, while organizations seek to find a rhythm in responding to and engaging with the virus and disease symptoms. We conceptualize this process of engaging with the virus and emerging organizational needs as 'a dance of agency' (Pickering 2012) in which the virus is 'the other' requiring organizational efforts and that must be moved with in a fluid and open-ended manner to find solutions to emerging issues.

 

We build on an extensive (and ongoing) ethnographic study in one university hospital that played a key role in the Dutch Corona crisis. As embedded researchers, we were able to study the crisis 'from within' through non-participatory observations of, and interviews with, crisis-management teams from the start of the crisis onwards. In addition, we conducted semi-structured interviews with nurse managers and nurses in four other hospitals in the Netherlands, interrogating them about the impact of the crisis on care provision and how hospitals organize and account for the care delivered. We provide a layered and in-depth account of how hospital organizations improvise and establish new organizational rhythms of organizing and providing care in uncertain times.

 

 

9.     Will the "new" become the "normal"? Exploring Sustainability of Rapid Health System Transformations

 

Carolyn Steele Gray, MA PhD (corresponding author) University of Toronto, Canada

 

James Shaw, PT, PhD, University of Toronto

 

Walter P. Wodchis, PhD, University of Toronto

 

Kerry Kuluski, PhD,

University of Toronto

 

Paul Wankah, MD, MSc, Université de Sherbrooke

 

Mylaine Breton, PhD, Université de Sherbrooke

 

G. Ross Baker, PhD, University of Toronto

 

Nick Zonneveld, Msc, University of Tilburg, The Netherlands

 

Henk Nies, PhD, University of Amsterdam, The Netherlands

 

Mirella Minkman, PhD, Vilans, centre of excellence for long-term care, The Netherlands

 

 

Abstract

Health, social and community care agencies are undergoing rapid changes in response to the COVID-19 pandemic. Arguably we are facing a "window of opportunity" in which "there is a heightened probability that efforts to alter a system state will be more likely to succeed" [1]. Some leaders for system transformation efforts seeking to improve integration of health and social care services are taking advantage of this window, hoping the changes put in place will advance, rather than upend, years of effort [2]. While there is an opportunity to progress integrated care, changes made in a turbulent environment may be unsustainable. The crisis literature cautions that in time compressed environments the emphasis is often on short-term needs, rather than longer term goals[3], which can have lasting long-term institutional impacts[4]. In addition, a major crisis like the pandemic creates economic and social dislocations which can limit the ability of systems to respond effectively. Thus despite efforts of systems to respond rapidly, questions remain regarding how this moment in time will impact the trajectory of transformation for integrated care initiatives.

 

This paper presents a theoretical framework and short case reports to explore whether rapid changes made in response to COVID-19: 1) advance integrated care and; 2) are likely to be sustained over time.

 

The Dynamic Sustainability Framework (DSF) [5] has been widely adopted to guide research and practice on sustainable adoption of new interventions. Taking a dynamic view of sustainability, DSF suggests interventions need to consistently adapt to fit with a changing environment. Disaster response/emergency theories argue that an assessment of the environment requires attention to pre and post disaster contexts to understand adoption and sustainability of interventions. This paper presents a blended theoretical approach, bringing together the DSF with Brundiers and Eakin's work from the disaster/response literature.

 

The proposed framework is applied to three cases from different jurisdictions to demonstrate applicability and suggest future research. The three selected cases capture some of the more prominent shifts occurring internationally. These jurisdictions were all undergoing transformation towards integrated health and social are service delivery prior to the start of the COVID-19 pandemic.

Case #1: Digitization/rapid virtualization in Ontario, Canada

Case #2: New partnerships occurring in Dutch Hills, Netherlands

Case #3: New accountability and governance structures in Quebec, Canada

 

This paper offers a theoretical contribution by bringing together health services and organizational behaviour literatures on sustainability with the literature on disaster/emergency response. The brief case reports illustrate the proposed relationships between components of the framework, and offer an early exploration of how rapid responses during a pandemic may, or may not, have lasting impact on systems that were seeking to shift towards greater integrated care delivery. While the cases focus on integrated care efforts, the theoretical grounding of this work may have wider applications to help others explore whether COVID-19 responses may lead to sustainable change over time. This framework will be tested through in-depth prospective comparative case studies.

 

 

10.  Reflecting the Clinical Gaze: Necropolitical Moments in a Pandemic

 

Professor Joanne Travaglia and Dr Hamish Robertson, University of Technology Sydney, Australia

 

Early on in the COVID-19 crisis, it became clear that health systems were not prepared to cope with the anticipated demand for acute services. Faced with the need to ration care, guidelines were issued by national bodies, and clinicians encouraged patients to exercise their right of control over their lives, and possible death. Yet unlike in previous crises, for example Hurricane Katrina in the USA, disquiet began to emerge early on. Examined through the lens of Mbembe's 2003/2017 framework of necropolitics, the state's right to decide who may live and who must die, these decisions and guidelines can be seen in a very different light.

Across the world reports have emerged about the implications of health systems attempts at prioritising care. In most cases prioritisation favoured young, well and non-disabled bodies. The rationale was that such people had a better chance of surviving. Underpinning this argument was the belief that the fairest way to allocate limited health resources is to allocate them to people where they would not be 'wasted'. This argument is seductive, not least of all because it reads as rational, impartial and objective.

This approach belies the fact that it makes vulnerable individuals and groups even more vulnerable, reinforcing the inequities associated with the social determinants of health. Feminist bioethicists have argued that capitalist systems have a deep antipathy towards dependent people. As so few healthcare systems are resourced to the level of actual population health need, they are rife with implicit and explicit narratives about the need to ration resources. We know that access to healthcare is inequitable even without a pandemic because healthcare systems reflect our social structures and their associated inequalities. The consequences of a pandemic scenario for people whose lives are already precarious may be especially serious.

Deep seated inequities are frequently exacerbated during emergency situations as in the case of COVID-19. In Britain, the National Institute for Health and Care Excellence's first release of COVID-19 critical care guidelines (later revised) disadvantaged patients with learning disabilities and autism. In Wales there were reports of care homes placing do not resuscitate (DNR) orders on the files of elderly patients without proper consultation. In Australia and elsewhere there were reports of General Practitioners 'encouraging' elderly patients to sign DNR orders so that they would not end up being 'burdens' on strained healthcare systems. While there may be no definitive answer to the question of who should survive, when it comes to choosing who will survive and who is likely to die, we need to consider how health systems and societies both historically and currently value and protect different patients. In this paper we will explore the risks to the vulnerable during times of crises, and the response to these risks during COVID19. We do this by focusing on the necropolitical dimensions of healthcare systems both in 'business as usual' and in crisis situations.

 

11.  Covid-19 and the flexibility of bureaucracy

 

Kirstine Zinck Pedersen and Paul du Gay, Copenhagen Business School, Denmark

 

Bureaucracy is commonly associated with a lack of the responsiveness, flexibility and innovative capability necessary for an organization to change rapidly when needed. However, with the Covid-19 crisis, we have seen large professional bureaucracies such as hospitals be able to change their organization, retrain their staff, establish new physical facilities, and introduce new guidelines, technologies and safety procedures with an astonishing speed. We have also seen ad hoc project teams, praised for their agility and innovative capacities, such as the Covid-19 crisis response team run by President Trump's son-in-law, Jared Kushner in the USA, fail abysmally to achieve any of their core tasks. While some might continue to suggest that flexibility  is a product of de-bureaucratization, we argue the opposite in this paper. Based on interviews with Danish healthcare managers and clinicians, we show how rapid and flexible responses during the Covid 19 crisis were linked to classic bureaucratic features such as clear lines of command, visible hierarchies, formalization, authority based on expertise and office-holding, and a focus towards the duties, purposes and ethics of office as the driving mobilizing force in making the reorganizations happen. 

 

 

12.  The temporal dimensions of health technology adoption during the Covid-19 pandemic: revisiting innovation theory to consider implications for health services and research

 

Jean Ledger, UCL, UK

 

Traditionally, innovation theory has focused on variable adoption timescales. In Rogers'1 seminal and socially framed concept of diffusion, innovations take time to spread through communication channels and social networks. New ideas may be taken up more rapidly, but this is due to their specific attributes and the actions of dedicated 'opinion leaders' and innovation champions. During the Covid-19 pandemic, however, timescales have been drastically shortened across the board with the fast uptake of digital technologies by health care providers, such as online consultations in primary and secondary care, driven by the necessity of physical distancing and protecting vulnerable members of the public. A global pandemic has therefore created an atypical innovation adoption context resulting in radical shifts in health service delivery. Practical problems that require urgent remedy have temporarily displaced many of the implementation barriers to service innovation cited in the health and organisational literature, such as cultural or professional resistance and a lack of incentives.

In this paper, we revisit Rogers' diffusion of innovation theory and recent service innovation frameworks2 in light of examples of digital health adoption in the UK, analysing how certain 'high compatibility' _digital health solutions have experienced an expedited rate of adoption. We suggest this is because, in the context of the pandemic, the combination of technological utility and user needs has created an ideal tipping point for digital tools to address system, organisational and professional problems. Of theoretical interest, the role of individual change agents, which is strongly emphasised in Rogers' original theory, has arguably become less central during Covid-19 compared to collective decision making at organisational and national levels, cooperation, and dedicated resources to support staff. We reflect on the prospect that certain digital health solutions that are less complex and confer observable benefits to health professionals and patients are likely to be sustained longer term, opening up new digital care service models and shifting workflows. Finally, we consider implications for the health services research community and whether certain assumptions about the temporal dimensions of innovation adoption should be revisited.

 

13.  What and whose science are the government following?  The organisation of scientific advice to government in the COVID-19 response.

 

Richard Gleave, Public Health England, UK

 

"We are following the science" is one of the standard lines used by government ministers in explaining their policy decisions on the response to COVID-19.  However both empirical studies and social theory have shown that science cannot be conceived as a single version of objective truth that enables unambiguous advice to be given to decision-makers that can then be universally implemented.  The media and public discourse during the pandemic has exposed the contested nature of science and the associated challenge of evidence-based policy and practice (Bacevic 2020).  In addition there has been an unprecedented spotlight on the scientists and the scientific organisations that provide this advice ((Winter 2020) (Elliot 2020)).

This paper will combine empirical data from the auto-ethnographic contemporaneous data collection of a senior manager working for Public Health England with organisational and public policy theory to show that the organisation of the production of scientific advice has been a significant factor in making the key policy decisions and their implementation. It will focus on two crucial elements on the organisation of scientific advice to government - the organisation of knowledge about COVID-19 and the organisation of advice-giving.

Firstly because advice is based on knowledge and because COVID-19 is a novel infection, the usual body of scientific research about the virus and the disease does not exist and so knowledge to inform policy and practice making is partial and emergent.  Even though empirical studies question the extent to which policy can ever be evidence-based ((Boswell 2018; Oliver et al. 2014)), the lack of conventional scientific research on COVID-19 means that other sorts of knowledge have been privileged in the pandemic.  Using theories and frameworks of evidence-based policy and practice ((Nutley, Walter, and Davies 2003; Smith 2013; Cairney 2016)), the alignment and tensions between epidemiological data, modelling, international comparative experience, expert opinion, story-telling and other sources of knowledge at crucial stages of the pandemic response will be explored. Secondly the advice is given by multiple actors.  The landscape of advice-givers includes a panoply of formal advisers and advisory organisations and a range of informal channels largely from the individual scientific commentator but also with embryonic informal organisational entities forming (Vaughan 2020).  SAGE, NERVTAG and PHE, Chris Whitty, Patrick Vallance and Neil Fergusson have visible identities in the media.  The legitimacy of the advice and advice-giver leads to competition and collaboration between organisational and individual actors which will be analysed using the concept of the "field" as developed in neo-institutional theory ((Scott 1994), (Zietsma et al. 2017)) and by Bourdieu (Bourdieu 1993). Never before has the machinery of providing scientific advice been so directly in the spotlight and this paper will explore the wider organisational issues that arise from this focus within the response to a global pandemic.

 

14.  Organisational learning and educational intervention in COVID-19 (Title check?)

 

Paula Rowland - Wilson Center, University of Toronto

 

Decisions to re-purpose and re-profile health services in response to the COVID-19 pandemic have mobilized a watershed of educational and training needs for health care providers from a wide range of professions. In Ontario, Canada, this re-organisation proceeded through two phases in the early stages of the pandemic. The first reorganisation of work was in preparation for a surge of critically ill patients. This reorganisation created a collection of continuing education (CE) interventions, related to "upskilling" and "reskilling" a cascade of health care providers into successively more acute settings of care. When this surge did not manifest, it became apparent that long term care centres were enormously vulnerable to COVID-19 outbreaks. The CE apparatus shifted abruptly, now providing training for health care providers (and members of the Canadian Armed Forces) to provide care in these community-based settings.

These two CE responses were rapidly mediated through a complex series of negotiations between health care organizations, educational institutes, professional associations, unions, professional regulatory bodies, and the provincial Ministry. Throughout this process, high stakes questions about knowledge, standards, governance, and jurisdiction were actively contested at a rapid pace. Tensions related to ethics, accountability, and responsibility manifested in the design, delivery and financial support of these CE interventions. Further, discrepancies between the power and privileges of the various professions, their governing relationships with health care organisations, and their status as "essential" to the COVID-19 effort were revealed. These contestations were largely in private (virtual) meetings, but also spilled over into public debates and documents shared more broadly on social media and organizational websites.

In this chapter, we will use Abbott's theorizing on systems of professions to sensitize our analysis of these educational responses to rapid re-organisation of care in one Canadian province. This will involve text analysis of publicly available documents within a single bounded case consisting of: an academic teaching hospital, affiliated educational institutions, the governing provincial ministry and various regulatory bodies and professional associations for the professions most implicated in the COVID-19 response (medicine, nursing, respiratory therapy, physiotherapy, and personal support workers). We will collect texts and statements related to requirements around CE, scopes of practice, accreditation of educational offerings, content of educational offerings, and assessment practices related to education.

 

In these moments of crisis and rapid response, we argue that CE acts as a mediating intervention between the professions and their newly transformed worksites. Our focus on CE responses to re-organisations of care provides an analytical window into these larger system dynamics. Further, these negotiations are taking place in worksites and in the public sphere, both enormously consequential arenas for determining the legitimacy and jurisdictional domains for each of the professions. The ways these controversies have been understood, navigated, and temporarily resolved have implications for the future of health care professions.  To that end, we aim to contribute to a broader theorization of the professions in health care, particularly related to changing conceptualizations of professionalism, the role of professions in society, and the relationships between professions and health service organizations.

 

 

15.  Exploring professional and hierarchical modes of organizing and their effects on inter-entity coordination processes and operational effectiveness: the case of French public hospitals during the sanitary outbreak

 

Olivier Saulpic and Philippe Zarlowski, ESCP Business School, France

 

During the sanitary outbreak in France, media interviews of medical practitioners and further anecdotal evidence seem to indicate that operational processes in public hospitals have been reorganized quickly across medical services and departments. This has enabled hospitals to operate effectively in a transversal mode, while the administration teams have been placed in a supporting role, to facilitate patient management and care activity in the hospitals. 

If it were confirmed, the change in the internal governance of operations in French public hospitals, and its effects, would offer a stark contrast with the organization and performance of hospitals before the crisis. Since the implementation of the French DRG-system in France and the implementation of the "new governance" for public hospitals (2006-08), recurring questions have been raised about the efficacy and unintended, detrimental effects of these reforms. The reforms have instituted new accountability mechanisms in public hospitals. Notably, they have created medical divisions, headed by doctors who report to the administrative executive team of the hospital. At the same time, as the new DRG-system enables the calculation of operating incomes at the level entities within the hospital, the internal performance management and measurement systems (PMMS) have been focused on the achievement of economic targets set for each medical division in a hierarchical, management by objective mode of organizing. Research projects on the implementation of the new management system in public hospitals and its effects, together with reports commissioned by French public authorities have documented that the reform did not lead to the anticipated levels of transformation and effectiveness in operational processes and care pathways. On the contrary, analyses tend to indicate that the new PMMSs would not facilitate, or would even constrain, inter-division coordination. The new organization may facilitate the mutualization of resources and the coordination processes within a division. However, it may also focus actors' attention on the local performance of their division, and the executive team of a division has few incentives, if any, to coordinate with other actors to improve the care pathways. Indeed, in the hierarchical accountability system, inter-divisional processes entail the complex negotiation of transfer prices and internal billings between divisions in a client-supplier mode.

During the sanitary outbreak, financial constraints and the focus on economic performance objectives have been released and medical practitioners have been placed at the center of decision-making processes, introducing a temporary shift from a hierarchical medico-economic logic to a more professionally driven model. While the focus on a single, urgent priority can contribute to explain the improvement in the hospital's' operational efficiency during the outbreak, it remains interesting to explore the proposition that the change in the internal governance of hospitals has also contributed to their efficiency and facilitated the coordination between entities. We also wish to try to understand the conditions under which this change could be sustained.

To that end, we plan to conduct interviews with doctors heading entities in three public hospitals in Paris. These interviews will aim to document examples of reorganization and new operating modes involving cooperation between entities, as well as the structures and decision-making processes that underpinned them. We also intend to analyze how they differ from the previous situation and whether this can contribute to account for the effectiveness of operations and inter-entity coordination during the time of the crisis, and to understand the conditions for their continuation beyond the crisis. Through our contacts in public hospitals in France, we have already secured that doctors heading medical entities which were at the center of patients' pathways during the outbreak will agree to participate in interviews, before or during the summer.

 

 

16.  Organisation behaviour for understanding and assisting healthcare response to covid 19 outbreak and beyond 

 

John Ovretveit, Director of Research, Professor of Health Improvement, Implementation and Evaluation, Medical Management Centre, The Karolinska Institutet, Stockholm, Sweden

 

From an organisations systems perspective the covid- 19 outbreak was not a single emergency event but an evolving process with an "emergent response" as services adapted to daily changes in information, demand and supply of resources. This article reports methods and early findings from a rapid implementation active research project into the emergency response of stockholm healthcare to the pandemic. One set of findings were that 

three emergent responses with different organisation and systems were undertaken corresponding to the three timescales of illness demand: emergency, resurgence, and upsurge of chronic mental and physical health. These responses need to be managed separately to, but coordinated with, existing routine service operations.

In dynamic situations the most effective type of response is an emergent data-driven iterative adaptive response. Implementation science discovers and applies strategies that are effective for implementing such responses and interventions for more effective clinical practice and service delivery. The article considers how to develop one stream of organisation behaviour research practice and theory to enable and evaluate responses to infectious disease outbreaks