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Medical leaders occupy a prominent position in healthcare policy in many countries, both in terms of the governance of quality and safety within healthcare organisations, and in broader system-wide governance. There is evidence that having doctors on hospital boards is associated with higher quality services. What is not known is how they have this effect. Analysing data collected from observations, interviews and documents from 15 healthcare providers in England (2014-2019), we elaborate the role of medical directors in healthcare governance as 'translation work', 'diplomatic work', and 'repair work'. Our study highlights the often enduring emotional effects of repeated structural changes to clinical services. It also contributes to theories of professional restratification, showing the work of medical directors as regional 'political elites', and as 'corporate elites' in publicly-funded healthcare systems.

Medical leaders occupy a prominent position in healthcare policy in many countries, both in terms of the governance of quality and safety within healthcare organisations, and in broader system-wide governance. There is evidence that having doctors on hospital boards is associated with higher quality services. What is not known is how they have this effect. Analysing data collected from observations, interviews and documents from 15 healthcare providers in England (2014–2019), we elaborate the role of medical directors in healthcare governance as 'translation work', 'diplomatic work', and 'repair work'. Our study highlights the often enduring emotional effects of repeated structural changes to clinical services. It also contributes to theories of professional restratification, showing the work of medical directors as regional 'political elites', and as 'corporate elites' in publicly-funded healthcare systems.

Over the past 50 years, two things have changed for women giving birth in high income nations; birth has become much safer, and now takes place in hospital rather than at home. The extent to which these phenomena are related is a source of ongoing debate, but concern about high intervention rates in hospitals, and financial pressures on health care systems, have led governments, clinicians and groups representing women to support a return to birth in 'alternative' settings such as midwife-led birth centres or at home, particularly for well women with healthy pregnancies. Despite this, most women still plan to give birth in high-technology hospital labour wards. In this article, we draw on a longitudinal narrative study of pregnant women at three maternity services in England between October 2009 and November 2010. Our findings indicate that for many women, hospital birth with access to medical care remained the default option. When women planned hospital birth, they often conceptualised birth as medically risky, and did not raise concerns about overuse of birth interventions; instead, these were considered an essential form of rescue from the uncertainties of birth. Those who planned birth in alternative settings also emphasised their intention, and obligation, to seek medical care if necessary. Using sociocultural theories of risk to focus our analysis, we argue that planning place of birth is mediated by cultural and historical associations between birth and safety, and further influenced by prominent contemporary narratives of risk, blame and the responsibility. We conclude that even with high-level support for 'alternative' settings for birth, these discourses constrain women's decisions, and effectively limit opportunities for planning birth in settings other than hospital labour wards. Our contention is that a combination of cultural and social factors helps explain the continued high uptake of hospital obstetric unit birth, and that for this to change, birth in alternative settings would need to be positioned as a culturally normative and acceptable practice.

Academic Health Science Centres (AHSCs) have been a key feature of the North American healthcare landscape for many years, and the term is becoming more widely used internationally. The defining feature of these complex organisations is a tripartite mission of delivering high quality research, medical education and clinical care. The biomedical innovations developed in AHSCs are often well documented, but less is known about the policy and organisational processes which enable the translation of research into patient care.This paper has two linked purposes. Firstly, we present a scoping review of the literature which explores the managerial, political and cultural perspectives of AHSCs. The literature is largely normative with little social science theory underpinning commentary and descriptive case studies. Secondly, we contribute to addressing this gap by applying a policy transfer framework to the English case to examine how AHSC policy has spread internationally. We conclude by suggesting a research agenda on AHSCs using the relevant literatures of policy transfer, professional/managerial relations and boundary theory, and highlighting three key messages for policy makers: (1) competing policy incentives for AHSCs should be minimised; (2) no single AHSC model will fit all settings; (3) AHSC networks operate internationally and this should be encouraged.

AbstractThe development and implementation of innovation by healthcare providers is understood as a multi‐determinant and multi‐level process. Theories at different analytical levels (i.e. micro and organisational) are needed to capture the processes that influence innovation by providers. This article combines a micro theory of innovation, actor‐network theory, with organisational level processes using the 'resource based view of the firm'. It examines the influence of, and interplay between, innovation‐seeking teams (micro) and underlying organisational capabilities (meso) during innovation processes. We used ethnographic methods to study service innovations in relation to ophthalmology services run by a specialist EnglishNHSTrust at multiple locations. Operational research techniques were used to support the ethnographic methods by mapping the care process in the existing and redesigned clinics. Deficiencies in organisational capabilities for supporting innovation were identified, including manager‐clinician relations and organisation‐wide resources. The article concludes that actor‐network theory can be combined with the resource‐based view to highlight the influence of organisational capabilities on the management of innovation. Equally, actor‐network theory helps to address the lack of theory in the resource‐based view on the micro practices of implementing change.

AbstractThere is variation in provision of social care in prisons. Our research aimed to understand variation across adult prisons in England and Wales, including: (1) what social care is provided? (2) who delivers social care? (3) what peer support initiatives are used? (4) what social care indicators are relevant? and (5) are there differences between prison type and social care provision? We analysed Her Majesty's Inspectorate of Prisons (HMIP) reports (published 2017–2020) from 102 prisons. From these reports we extracted and analysed data on social care provision. Elements of social care are not consistently delivered; need assessments (81.4 per cent) and referrals (75.5 per cent) were most frequently reported. Different providers (health care/social care/prison) deliver social care. Forty-one prisons (40.2 per cent) included peer support (formal to informal). We found no notable differences between prison categories and social care delivery, although, within category D prisons, a significantly larger proportion of those with a disability reported receiving support they needed. Inspection reports highlighted that prison social care should mirror community social care, but we could not fully evaluate this due to reporting issues. Social care provision varies; effectiveness of different models is not yet known. We provide recommendations to improve social care reporting within HMIP reports.

Objective: To develop an assessment of bed need that was as little affected by personal biasas possible. Method: The Bed Requirement Inventory (BRI) is an eight-point scale designed to identify the appropriate use of an acute psychiatric bed. This is completed by a member of the ward staff, usually a nurse, and takes 5 minutes to fill in. The reliability, validity and feasibility of using the scale in normal practice were tested in a one-year study, and variations ininappropriate bed use described. Results: The inter-rater reliability of the scale was good (intra-class correlation coefficient = 0.63) and a comparison of the need for a psychiatric bed (comparing the BRI score with the judgement of an independent multidisciplinary group of professionals) also showed good agreement (k 1/4 0.69), suggesting reasonable validity (although when the assessment was made by the named nurse agreement was less good). Results from a year-long survey in two West London hospitals showed that 17% of admissions were inappropriate and 32% had delayed discharge, black Caribbean patients had a significantly higher proportion (25%) of inappropriate admission than others (11%) and those referred from housing charities andhostels had a higher proportion (50%) of inappropriate bed use at some time than other groups(33%). Conclusions: The Bed Requirement Inventory is a quick and reliable method of determiningthe appropriate use of a psychiatric bed and could be of use in estimating local bed needs. Delayeddischarge remains a serious reason for inappropriate bed use in London.

© 2018 The Author(s). Background: The implementation of strategic health system change is often complicated by the informal politics and power of health systems, such as competing interests and resistant groups. Evidence from other industries shows that strategic leaders need to be aware of and manage such 'organisational politics' when implementing change, which involves developing and using forms of political 'skill', 'savvy' or 'astuteness'. The purpose of this study is to investigate the acquisition, use and contribution of political 'astuteness' in the implementation of strategic health system change. Methods: The qualitative study comprises four linked work packages. First, we will complete a systematic 'review of reviews' on the topic of political skill and astuteness, and related social science concepts, which will be used to then review the existing health services research literature to identify exemplars of political astuteness in health care systems. Second, we will carry out semi-structured biographical interviews with regional and national service leaders, and recent recipients of leadership training, to understand their acquisition and use of political astuteness. Third, we will carry out in-depth ethnographic research looking at the utilisation and contribution of political astuteness in three contemporary examples of strategic health system change. Finally, we will explore and discuss the study findings through a series of co-production workshops to inform the development and testing of new learning resources and materials for future NHS leaders. Discussion: The research will produce evidence about the relatively under-researched contribution that political skill and astuteness makes in the implementation of strategic health system change. It intends to offer new understanding of these skills and capabilities that takes greater account of the wider social, cultural organisational landscape, and offers tangible lessons and case examples for service leaders. The study will inform future learning ...