“It’s a complex mesh”- how large-scale health system reorganisation affected the delivery of the immunisation programme in England: a qualitative study

Abstract

BackgroundThe English health system experienced a large-scale reorganisation in April 2013. A national tri-partite delivery framework involving the Department of Health, NHS England and Public Health England was agreed and a new local operational model applied. Evidence about how health system re-organisations affect constituent public health programmes is sparse and focused on low and middle income countries. We conducted an in-depth analysis of how the English immunisation programme adapted to the April 2013 health system reorganisation, and what facilitated or hindered the delivery of immunisation services in this context.MethodsA qualitative case study methodology involving interviews and observations at national and local level was applied. Three sites were selected to represent different localities, varying levels of immunisation coverage and a range of changes in governance. Study participants included 19 national decision-makers and 56 local implementers. Two rounds of interviews and observations (immunisation board/committee meetings) occurred between December 2014 and June 2015, and September and December 2015. Interviews were audio recorded and transcribed verbatim and written accounts of observed events compiled. Data was imported into NVIVO 10 and analysed thematically.ResultsThe new immunisation programme in the new health system was described as fragmented, and significant effort was expended to regroup. National tripartite arrangements required joint working and accountability; a shift from the simpler hierarchical pre-reform structure, typical of many public health programmes. New local inter-organisational arrangements resulted in ambiguity about organisational responsibilities and hindered data-sharing. Whilst making immunisation managers responsible for larger areas supported equitable resource distribution and strengthened service commissioning, it also reduced their ability to apply clinical expertise, support and evaluate immunisation providers’ performance. Partnership working helped staff adapt, but the complexity of the health system hindered the development of consistent approaches for training and service evaluation.ConclusionThe April 2013 health system reorganisation in England resulted in significant fragmentation in the way the immunisation programme was delivered. Some of this was a temporary by-product of organisational change, other more persistent challenges were intrinsic to the complex architecture of the new health system. Partnership working helped immunisation leaders and implementers reconnect and now the challenge is to assess how inter-agency collaboration can be strengthened.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1711-0) contains supplementary material, which is available to authorized users.

Is partnership the answer? Delivering the national immunisation programme in the new English health system: a mixed methods study

“…Health system reorganisation is known to disrupt effective collaborative networks [5, 15] and require staff to expend significant effort to re-establishing partnerships and make sense of new organisational arrangements [7]. In this context, it is easy for partnership working to become a means in itself rather than a means to an end.…”

“…The questionnaire (Additional file 1) was informed by the findings of the preceding study [7] and arranged into four sections: ‘Professional demographics’, ‘Individual and organisational responsibility for immunisation’, ‘Working with others to manage the immunisation programme’, and ‘Evaluating programme uptake and service quality’. It comprised of 38 questions and took 20–30 min to complete; response options included Likert scales, multiple choice, binary data and free text.…”

“…It comprised of 38 questions and took 20–30 min to complete; response options included Likert scales, multiple choice, binary data and free text. The online questionnaire and distribution platform were tested internally and piloted with eight participants from the preceding study [7].…”

“…Immunisation provides an interesting example of the role partnerships can play in managing public health programmes. In a preceding study we found that ‘partnership work’ was critical in the reintegration of the immunisation programme after the major reorganisation of the English national health system (NHS) in April 2013 [7]. This reorganisation was triggered by the Lansley’s 2012 Health and Social Care Act [8] and resulted in significant changes to delivery of the immunisation programme and the delegation of responsibilities.…”

Social enterprises and public health improvement in England: a qualitative case study

“…Chantler et al 11 found that the growing complexity of commissioning arrangements for immunisation had led to fragmentation which entailed risks for evaluation and monitoring, and potentially large transaction costs in managing multiple small contracts. In our study, there were reported attempts to mitigate similar risks through alliance contracts that involve multiple providers, and offering larger block contracts, either geographically, or for a broader range of services.…”