Organizational Transformation and Top-Down Change: The Case of the NHS

This paper analyses the effects of government-sponsored attempts to change the way that the NHS, one of the largest employers in Europe, is managed. The theoretical issues raised relate to the concept of transformational change and attempts at public-sector restructuring, which set the context for the presentation of data. The empirical research, carried out over three years, examines the changes since the most recent reforms (the NHS and Community Care Act 1990).
The research considers the extent of organizational change which can be seen as the outcome of these reforms in relation to: a multiple and inter-related change agenda; the creation of new forms of organization; the creation of new roles; the reconfiguration of power relations; and the creation of a new culture, ideology and organizational meaning. These are presented as the key variables which could indicate whether transformational, rather than incremental, change has occurred. The focus of this analysis is at local board level.
This article concludes that earlier analyses of the limited success of administrative reform are no longer the case. Our analysis of the key variables suggests that what is occurring at least at local board level goes beyond incremental change and may represent the beginnings of an 'organizational transformation'. This contains unintended as well as intended elements as an unanticipated 'hybrid' form of management may be emerging.     

Evaluating Children's Services: Recent Conceptual and Methodological Developments

This article considers recent innovations and challenges withrespect to the evaluation of children’s services interventions.It sets out a method for designing and evaluating services thatis based on research evidence gathered on individual cases andthat permits revision of those services in the light of emergingresults. It starts by describing briefly different ways of identifyinga discrete group of children with similar needs. It then outlinesapproaches to ensuring that an intervention for those childrenis underpinned by theory and research evidence–includingthe idea of ‘logic modelling’–before discussingthe importance of capturing accurately how well the interventionis implemented. Experimental and non-experimental methods ofassessing an intervention’s effectiveness are considered,with particular emphasis on techniques for enhancing the causalinference that can be drawn from studies and the importanceof matching method and purpose. The article also demonstrateshow the principles and methods used in relation to evaluatingservices for groups can be applied in clinical work with individualcases, and identifies the benefits of this general approachto evaluation over and above the information that it provideson what works.     

A Social-Cognitive Perspective of Terrorism Risk Perception and Individual Response in Canada

The volume of research on terrorism has increased since the events of September 11, 2001. However, efforts to develop a contextualized model incorporating cognitive, social-contextual, and affective factors as predictors of individual responses to this threat have been limited. Therefore, the aim of this study was to evaluate a series of hypotheses drawn from such a model that was generated from a series of interviews with members of the Canadian public. Data of a national survey on perceived chemical, biological, radiological, nuclear, and explosives (CBRNE) terrorism threat and preparedness were analyzed. Results demonstrated that worry and behavioral responses to terrorism, such as individual preparedness, information seeking, and avoidance behaviors, were each a function of cognitive and social-contextual factors. As an affective response, worry about terrorism independently contributed to the prediction of behavioral responses above and beyond cognitive and social-contextual factors, and partially mediated the relationships of some of these factors with behavioral responses. Perceived coping efficacy emerged as the cognitive factor associated with the most favorable response to terrorism. Hence, findings highlight the importance of fostering a sense of coping efficacy to the effectiveness of strategies aimed at improving individual preparedness for terrorism.     

Assessing the treatment effect in a randomized controlled trial with extensive non‐adherence: the EVOLVE trial

Intention‐to‐treat (ITT) analysis is widely used to establish efficacy in randomized clinical trials. However, in a long‐term outcomes study where non‐adherence to study drug is substantial, the on‐treatment effect of the study drug may be underestimated using the ITT analysis. The analyses presented herein are from the EVOLVE trial, a double‐blind, placebo‐controlled, event‐driven cardiovascular outcomes study conducted to assess whether a treatment regimen including cinacalcet compared with placebo in addition to other conventional therapies reduces the risk of mortality and major cardiovascular events in patients receiving hemodialysis with secondary hyperparathyroidism. Pre‐specified sensitivity analyses were performed to assess the impact of non‐adherence on the estimated effect of cinacalcet. These analyses included lag‐censoring, inverse probability of censoring weights (IPCW), rank preserving structural failure time model (RPSFTM) and iterative parameter estimation (IPE). The relative hazard (cinacalcet versus placebo) of mortality and major cardiovascular events was 0.93 (95% confidence interval 0.85, 1.02) using the ITT analysis; 0.85 (0.76, 0.95) using lag‐censoring analysis; 0.81 (0.70, 0.92) using IPCW; 0.85 (0.66, 1.04) using RPSFTM and 0.85 (0.75, 0.96) using IPE. These analyses, while not providing definitive evidence, suggest that the intervention may have an effect while subjects are receiving treatment. The ITT method remains the established method to evaluate efficacy of a new treatment; however, additional analyses should be considered to assess the on‐treatment effect when substantial non‐adherence to study drug is expected or observed. Copyright © 2015 John Wiley & Sons, Ltd.     

Caring for informal caregivers: policy approaches to the provision of direct support services

Despite being the backbone of modern welfare states, the informal care sector for elderly people in need of long-term care is highly dysfunctional. The majority of informal caregivers are overburdened on account of their care-related activities, although an evolving market for support services directly aimed at relieving informal caregivers is observable. In this paper, we examine the reasons for the imperfect exchange between demand and supply in this market, applying the economic theory of market failure. Through a case study of Austria based on an empirical, qualitative survey of all direct support services and their suppliers on the national level as well as in three provinces, an understanding of this market's main players and mechanisms is derived. Thus, the authors determine that three different system types can be identified beyond the historical regional discrepancies. They illustrate the approaches to service provision for informal caregivers: centralized and public, laissez-faire and private, and a radically decentralized network for informal caregivers. Still, lack of information, social and psychological barriers, as well as high transaction costs, are identified which undermine the support service market for informal care. If the costs of the formal long-term care sector are to be contained despite demographic developments, better policy approaches will be necessary to overcome this challenge. In light of this, recommendations are derived to ensure a better exchange between supply and demand. By providing an initial empirical understanding and analysis of this market and its imperfections, the authors pioneer future quantitative research in this field.     

A Multi-state Piecewise Exponential Model of Hospital Outcomes after Injury

To allow more accurate prediction of hospital length of stay (LOS) after serious injury or illness, a multi-state model is proposed, in which transitions from the hospitalized state to three possible outcome states (home, long-term care, or death) are assumed to follow constant rates for each of a limited number of time periods. This results in a piecewise exponential (PWE) model for each outcome. Transition rates may be affected by time-varying covariates, which can be estimated from a reference database using standard statistical software and Poisson regression. A PWE model combining the three outcomes allows prediction of LOS. Records of 259,941 injured patients from the US Nationwide Inpatient Sample were used to create such a multi-state PWE model with four time periods. Hospital mortality and LOS for patient subgroups were calculated from this model, and time-varying covariate effects were estimated. Early mortality was increased by anatomic injury severity or penetrating mechanism, but these effects diminished with time; age and male sex remained strong predictors of mortality in all time periods. Rates of discharge home decreased steadily with time, while rates of transfer to long-term care peaked at five days. Predicted and observed LOS and mortality were similar for multiple subgroups. Conceptual background and methods of calculation are discussed and demonstrated. Multi-state PWE models may be useful to describe hospital outcomes, especially when many patients are not discharged home.