Editorial

Citation

Maniatopoulos, G., Hunter, D. and Best, A. (2020), "Editorial", Journal of Health Organization and Management, Vol. 34 No. 3, pp. 233-236. https://doi.org/10.1108/JHOM-05-2020-367

International perspectives on health systems transformation

The recent coronavirus disease 2019 (COVID-19) pandemic is a timely reminder of the need for health systems to take co-ordinated and rapid emergency responses to prevent and reduce the risks of infection, sickness and loss of life. With health systems globally facing new and complex challenges such as unprecedented life expectancy; an increase in the prevalence of non-communicable diseases and multimorbidity much of which is avoidable; and the globalization of infectious diseases, transforming the way services are organised and provided to improve population health, quality and patient safety has become an urgent priority for policymakers (WHO, 2016, 2018; Braithwaite, 2018; Hunter, 2016; Best et al., 2012). However, at a time of ongoing political and economic uncertainty and epidemiological transition characterized by demographic, societal and health status changes, large-scale health systems transformation (HST) is not always an easy task. It requires new reconfigurations of practice at multiple levels reflecting the dense interconnections of highly complex systems (Greenhalgh et al., 2017, 2012; Maniatopoulos et al., 2015). But many health systems lack the infrastructure, resources and capacity to respond to policy pressures for health reform and systems improvement. At the same time, competing priorities, intra- and inter-organisational boundaries across care settings, fragmentation of services and the rapid pace of change within the policy environment impose huge challenges for the successful implementation of HST programmes.

Observations from our own research and recent experience suggest that current policy pressures for health systems to improve outcomes and reduce inequalities at a time of increasing financial stringency and uncertainty combine to create a huge challenge that, if not met successfully, could negatively affect progress (Maniatopoulos et al., 2019; Hunter et al., 2015; Best et al., 2012). In the UK, growing pressures on the National Health Service (NHS) to meet government targets and release efficiencies have highlighted the need to move away from top-down structural approaches to HST towards the development of new care models at the local level where integrated systems and infrastructures to support ongoing and emergent innovation in use can emerge and evolve over time. With the publication of the NHS Long-Term Plan (NHS England, 2019) further developments with Integrated Care Systems and place-based approaches to health and well-being are being introduced. These approaches have given permission to local areas to chart their own destinies within a national framework of health and social care integration and systems improvement. Similarly in Canada the need to coordinate implementation of clinical care guidelines across jurisdictions and across policy, executive and practitioner levels requires clear and consistent, coordinated strategy to prepare the system for change, promote shared leadership, strengthen knowledge management, implement ongoing communication and support local networks (Best et al., 2016). In this context, understanding the inherent complexity of transforming health systems has become a central theme in global health policy discourse and academic research alike.

Aim of special issue

This special issue aims to address some of the challenges and lessons learnt from international attempts to implement large-scale transformation programmes to achieve integrated health and social care. For the purposes of this special issue large-scale transformation programmes are defined as “interventions aimed at coordinated, system-wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of healthcare delivery, the quality of patient care and population-level patient outcomes” (Best et al., 2012, p. 422). Drawing upon complexity theory, the special issue explores the development and implementation of health and social care initiatives to address current challenges and opportunities brought about by large-scale change initiatives. In doing so, we reflect on the current state and practice of international experiences from academic, policy and practitioner perspectives in the health and social care sectors. Our particular focus is on the How of transformation, rather than the Why and the What which directs attention to going beyond mere description to identifying and analysing the enablers and barriers to change efforts. In this context, this special issue contributes to the social study of HST programmes and policy implementation.

The seven papers collected together here provide examples of research activity illustrating the spectrum of health and social care transformation programmes and lessons learnt about such large-scale change initiatives. With contributions from Europe (the UK and the Netherlands), Australia and Canada, it explores the nature, character and implications of large-scale transformation initiatives, examining empirically and analytically the complexity and multifaceted nature of health systems change to reflect the requirement for learning to inform future reform programmes.

The first paper by Braithwaite et al. reports on a study that analysed health system reform and improvement efforts in 60 countries and lessons learnt for policymakers. Drawing upon a comparative analysis, the authors provide a model of what constitutes successful systems change across a wide sample of health systems, offering a store of knowledge about how reformers and improvement initiators achieve their goals.

MacLeod's et al. focus on wide-scale transformation in primary healthcare provides a comprehensive exploration into how partnering for primary healthcare transformation is messy and complicated but can create a foundation for whole system change. Drawing upon a longitudinal qualitative case study in a health region in Northern British Columbia (BC), Canada, the paper highlights the strength of vision, commitment and opportunism needed to bring about system change in the context of “real world” complexity that is so characteristic of healthcare transformation initiatives.

The paper by Steenkamer et al. reports on a qualitative study with key stakeholders involved in the design and implementation of significant population health management programmes in four very different national and regional contexts. Drawing upon a realist methodology, the paper highlights initial programme theories for the implementation of population health management programmes including different strategies and structures underpinning the initiatives. These insights provide a deeper understanding of how large-scale transformation could be developed in these different contexts.

The paper by Sheaff et al. focusses on managerial workarounds at organisational and interorganisational level with respect to Diagnostic-Related Group (DRGs) hospital payment systems in England, Germany and Italy. Drawing upon a comparative case study, the paper explores how attempts to transform hospital payment systems in three European health systems involve managerial workaround intended to repair and not resist policy. In doing so, the authors aim to extend the concept of workaround for application to managerial activities such as the transformation of health systems by means of DRG payment systems.

Best et al. report on a study that developed the evaluation strategies of BC's provincial response to a public health emergency: drug-related overdose deaths. It sets out the challenges of evaluating such a complex, multifaceted response involving many different agencies in public health, primary care, social services and other care sectors and how they were overcome. In doing so, it provides a pragmatic example of the rationale and issues faced to address the what, the why and particularly the how in evaluating large-scale, multi-level, multisectoral change.

The paper by Maniatopoulos et al. focusses on the implementation of the new care models programme in the English NHS to support system-wide transformation of health and social care service delivery. Drawing upon recent theoretical developments on the multilevel nature of context, it highlights the wider national policy context in which large-scale health system transformation takes place as well as the perceptions of front-line staff members and service users in order to establish the degree of alignment or, conversely, to identify where policy and practice are at risk of pushing and pulling against each other.

The final paper by Fitzgerald and Biddle explores system change initiatives in England's NHS cancer services. Drawing upon a change framework grounded in systems thinking, it explores the similarities and dissimilarities of the dynamics of change experienced by eight cancer service implementation projects as part of the Accelerate, Coordinate, Evaluate Programme. In doing so, it outlines the nature of the challenges encountered, the tactics deployed in response, together with the factors observed to help change thrive.

Future challenges

The body of research presented in this issue is a representation of HST initiatives currently undertaken internationally aiming to strengthen health systems and improve patient and population health outcomes. While we acknowledge that each of the reported initiatives had different aims and purposes, local arrangements and practices all highlight the complex and multifaceted nature of such programmes. We hope that these examples contribute to the development of a more comprehensive analysis of the processes surrounding the implementation of large-scale transformation initiatives and policy. Understanding the features of successful transformation is integral to the development of improvement policies and strategies in healthcare systems. Events surrounding COVID-19 and its rapid spread are a reminder of how the unpredictable can occur without warning and be game-changing. They raise questions about the readiness of health systems to adapt and respond appropriately to public health emergencies. But the wider lesson is that all successful HST requires readiness for change on the part of policymakers and those charged with its implementation (Nuno-Solinis, 2018; Ritchie and Straus, 2019). Without it, or reconfigurations across a multilevel set of practices in place (Maniatopoulos et al., 2015), policy failure will be the likely result.