Foreword

Editorial

Health futures in health service management research: Turning ideas into actions and vice versa

In this issue of HSMR, we are pleased to embrace a thorough understanding on the health futures in health service management research, starting with interesting primary research papers that were presented at the 2017 EHMA conference as well as a sharp viewpoint on the 70th anniversary of the British National Health Service at its turning chameleon point to grip the future.

Whereas today innovations in the healthcare management spring out across the broad spectrum of health service delivery, prompted either by disruptive technologies and the search for curbing the healthcare expenditures, the articles here published provide insights on the impacts of innovations from the health service management perspectives. Underneath, there are at least two streams that bond the analyses and reflections the authors pursued.

Foremost, the increasing call for patient-centred care in healthcare management and how healthcare organisations, governance, workforce up to the overall healthcare systems design are influenced and could react to put it forward. And, consequently, to what extent the so-called science of improvement, ¹ or the generalisation and learning from the implementation stages, is scaling up health service management research and enshrining new ways of understanding and devising alliances between theories and practices. Since 2001, the Institute of Medicine’s ² quality chasm reported patient-centeredness as one of the six aims for improving care, along with safety, effectiveness, timeliness, efficiency and equity. Nonetheless, after more than a decade, healthcare systems and organisations are still striving for moving out from theories and labels.

Whether the early proponents of patient-centred care were well aware of the huge implications of such an approach is a question here to stay. Indeed, a good piece of improvement could be found more in experiences executed and the challenging questions they are continuously raising to the traditional understanding of healthcare disciplines and are colonising the debate and influencing the literature’s advances. The focus on individual needs in fact downturned the traditional evidence-based approach, which focuses on populations; in fact, the first goal of the value-based care movement has been the acceptance of the art of generalisations and the science of particulars – as today is widely recognised that a good outcome must be defined as what is meaningful and valuable to the individual patients. Indeed, experiences proved that patient-centred care is the result of a mix of quality of personal, professional and organizational relationships as well as of the health systems’ governance. Thus, efforts to promote patient-centred care should take into account and bond together the complexity of this mix and deal with it. For instance, training physicians for empowering patients transforms their role from one characterised by professional dominance to one that should hinge on compassionate leadership, ³ seeking for collaboration with other professionals, empathy, solidarity and collaboration.

The responsibility to improve care is an intrinsic part of clinical practice, not simply an add-on. Nevertheless, patient-centred experiences showed that improvement is less a physical or biological discipline than a behavioural and social science that brings the epistemology of clinical science research methods together with the human needs of patients and clinicians. Put in other words, the search for patient-centred care is accelerating a Copernican revolution in our traditional research and understanding of healthcare services, featured by the fragmentation and heterogeneity of different epistemologies and disciplines to grasp key concepts as time, quality, adherence and compliance. For instance, Lloyd and Goldmann ⁴ raised a question over the disruption of the traditional three concepts of medical time (research, practice and illness perceived by the patients), which are contradictory as they lie within the scientific method. Indeed, they suggest to focus on the ‘improvement time’ that potentially could unify the rigorous scientific perspective of linear time (the Greek kronos) and the personal and emotional perspective (the Greek kairos). On the same line, Berwick ⁵ recently devised the beginning of a third ‘Era of Medicine’, namely the Era of Morale, which follows the Era 1 of professional dominance and Era 2 of accountability and market theory. And the Era of Morale is featured by all the factors that could boost and put forward patient-centred care, and mostly listed in quality chasm, even though the author stressed once again the value of the science of improvement and the need of cross-fertilisation between research methods and disciplines to meet it.

Patient-centred care is therefore demanding, ⁶ and whereas is prominently positioned on the political agendas internationally, more time, experiences, and research swallowing from theories to practices and vice versa are needed. This special issue of HRSM indeed tackles the management perspective on patient-centred care, analysing the bedrocks of healthcare management, wherein we should raise questions over adequate measures to understand quality improvement within healthcare organisations and professionals. In fact, drawing on results from multiple case-study analysis, two articles tackle out and discuss the momentum that lean management and process mapping, namely operation management, are gaining. Exploring the literature gaps on how lean interventions are intertwined with the organisational context, Centauri et al. call for a system-wide implementation approach. The article provides a deeper understanding on this inner relation and the interplay between different organisational dimensions (social, technical and the external environments); indeed, the paper ends up with a lesson learned from research to implementation, identifying the key factors that both managers and policy makers should take into account when implementing organisational-wide improvements exploiting lean approaches. In a similar vein, the primary research from Antonacci et al. explores the use of process mapping to meet quality improvements. Whereas findings show the benefits and versatility of using process mapping, they also stressed that the ease of this method should be carefully managed because its success relies on multiple variables, yet with the project team yet the organisational environment’s complexity. The more complex a process, the more the clinical and organizational knowledge about it is likely to be fragmented, and the more likely that stakeholder objectives and interests may conflict.

Beyond process integration and streamline to meet patient-centeredness delivery, another critical impact of integration deals with organisations’ merges and the set-up of integrated delivery networks through strategic alliances between providers. Analysing multiple cases, the work from Romiti et al. explore whether alternative governance modes (i.e. merger or alliance) could represent progressive steps of integration or stand-alone strategies compared to full vertical integration. Experiences analysed pointed out at least three key understandings: alliances and mergers could represent different steps compared to integration’s strategies among organisations; the time scale of integration processes holds a critical role and there should be an alignment between the system-level integration and organisational processes to achieve integration; finally, trust nurtures and fuels integration processes across all levels, from the system to the organisations and the frontline integration among professionals involved.

Lee et al., indeed, present the results from a PhD work on the use of health workforce planning methods to improve system capacity to meet population health needs. Whereas there is a growing literature on the efficacy and usefulness of workforce planning tools, uncertainty could hamper their predictive capacity. The work thus analyses and discusses the importance of adopting mix methods in forecasting the future workforce, to improve the limitations of conventional tools based on clinical perspectives and information. The approach described offers workforce planners and policy makers some guidance on the use of complimentary data and methods to overcome these limits, and a framework for exploring the complexities of the workforce’s evolution in the near future.

Finally, the issue guests the commentary from Martin Powell on the 70 years of the British National Health Services, reflecting how this anniversary is shading new lights on the role of the Labour Party and the Ministry of Health at the creation of the NHS. The long shadow of Bevan, is argued, casts the evolution of the NHS: as an embodiment of the NHS; as rhetoric; as trust; and as reassurance. Beyond the critical invocations featuring the political and the academic debates, at the national level, the Bevan shadow has been always considered the undeniable father of the NHS. Thus, the commentary ends up with another provocative invocation to rename the British NHS as a ‘Bevan system’, giving up with the traditional use of ‘Beveridge’ label in the literature. The latter in fact is puzzling from the theory perspective and indeed compared to the role Sir Beveridge played at the birth of the NHS.

Verdiana Morando