Developing reconfiguration plans for integrated urgent and emergency care systems [EUCSs] – An examination of stakeholder perspectives of change

摘要

Introduction : While proponents of integrated EUCSs claim that such models deliver higher quality, safety and efficiency standards without introducing spatial inequalities [1], a conflicting view is that reconfiguration is usually performed for political reasons and represents a conflict of values between different stakeholder groups [2]. A series of EUCS reconfiguration programmes have recently been implemented, albeit to varying degrees, in the Republic of Ireland. This study investigated stakeholder perspectives on the rationale of this initiative. It considered the hypothesis that individuals from different stakeholder groups will endorse different positions in relation to reconfiguration. Methods : Documentary analysis was used to identify the official justifications for change in region-specific reconfiguration planning documents. Semi-structured interviews with 175 purposively sampled stakeholders explored their perspectives on the rationale for this remodelling of care across the country. They comprised ‘internal’ (hospital staff) and ‘external’ stakeholders (general practitioners, ambulance personnel and members of the public including local politicians and hospital campaign groups). Framework analysis was used. Results : While a majority of stakeholders agreed with the need for an accessible and well-functioning health system, their understanding of what it meant and how it should be achieved in the delivery of urgent and emergency care varied considerably between the two stakeholder groups. There was some cynicism predominantly among external stakeholders as to the true motivations behind reconfiguration. They broadly perceived decision-making around service change to be influenced by political and cost-saving concerns. Discussions : Findings mirror experiences in other countries [2]. Considerable public angst has been documented over the safety issue of centralising services and associated risks potentially involved in having to travel longer distances for emergency care [3]. People have perceived service change as cuts to services [4]. Proponents of change have tended to emphasise the perceived quality and safety benefits of reconfiguration rather than focusing on cost-savings [5]. Conclusions : When it comes to reconfiguration, there are clear differences depending on stakeholder position on what a health service should look like in the delivery of EUCS care. A ‘win for all’ scenario is perceived as unattainable for there is always a trade-off of interest. Understanding what concerns the public and the trade-offs that patients and their families are prepared to make when deliberating over major service change would help those tasked with planning EUCS provision to make decisions that address the range of issues at hand. Lessons learned : Where regions have not been fully reconfigured, findings will inform those in the driving seat of change of the diversity of viewpoints on EUCSs. It will enable them to understand the concerns, misconceptions and conflicting perspectives that hinder a united effort to improving care. Limitations : This was a retrospective study. There was also discrepancy in the sum of stakeholders interviewed in each region, particularly in one region, although extensive and well documented reconfiguration had taken place there which provided a larger sample frame to recruit from. Suggestions for future research : The extent to which lessons learned from this study inform EUCS policy implementation in regions not fully reconfigured is a possible avenue for research. References : 1- Ham C, Smith J, Temple J. Hubs, spokes and policy cycles: a paper for the King’s Fund London Commission. London: King’s Fund; 1998. 2-Spurgeon P, Cooke M, Fulop N, Walters R, West P, Perri S, Barwell F, Mazelan P. Evaluating models of service delivery: reconfiguration principles. National Institute for Health Research Service Delivery and Organisation programme. London: HMSO; 2010. 3- Farrington-Douglas J, Brooks R. The future hospital: the politics of change. London: Institute for Public Policy Research; 2007. 4- Farrington-Douglas J, Brooks R. The future hospital: the progressive case for change. London: Institute for Public Policy Research; 2007. 5- Fulop N, Walters R, Spurgeon P. Implementing changes to hospital services: Factors influencing the process and ‘results’ of reconfiguration. Health Policy; 2012; 104:128-135.