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Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring 'practice languages' is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor 'care pathway' is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as 'designing a pathway' may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use. [ABSTRACT FROM AUTHOR]

Objective: This paper aims to explore the nature of clinical commissioning groups (CCGs) in England as membership organizations. Utilizing the concept of meta-organization as a lens, we discuss the impact that this organizational form might have on CCGs' ability to become 'strategic commissioners'. Methods: We used a longitudinal qualitative approach to explore the adoption and implementation of primary care co-commissioning. The study was undertaken between May 2015 and June 2017 and included interviews with senior policy makers, analysis of policy documents, two telephone surveys, and case studies in four CCGs nationally. Results: CCGs operate as membership organizations with closed boundary and low stratification, whereby a consensus or majority needs to be reached by members when activities impact on membership or the CCG's constitution. While CCGs should move towards a more strategic commissioning role that is focused on local priorities agreed by their members, they are faced with a complex system of accountabilities and responsibilities, which makes this difficult to achieve. Conclusions: The nature of CCGs as membership-based meta-organizations has the potential to both help and hinder CCGs in becoming strategic commissioners. The complexities in accountability and governance that the membership approach introduces, and the potential difficulties that CCGs face with competing meta-organizations, raises questions about the future of CCGs as membership organizations. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to investigate the perceptions of key informants on a national support programme for the development of new care models (NCM) in England (2015/2016–2017/2018). It focuses on the perceived facilitators and barriers affecting the development and implementation of the NCM programme and offers some insight into the role of national level support in enabling local integration initiatives. Design/methodology/approach: A set of 29 interviews were carried out with a variety of respondents at the national level (including current and past programme leads, strategic account managers, advisors to the programme and external regulators) between October 2017 and March 2018, and analysed thematically. Findings: A set of facilitative elements of the programme were identified: the development of relationships and alliances, strong local and national leadership, the availability of expert knowledge and skills, and additional funding. Challenges to success included perceived expectations from the national Vanguard programme, oversight and performance monitoring, engagement with regulators, data availability and quality, as well as timetables and timescales. Crucially, the facilitators and challenges were found to interact in dynamic and complex ways, which resulted in significant tensions and ambiguities within the support programme. Research limitations/implications: While the sample was drawn from a range of different senior players and the authors ensured a diverse sample associated with the NCM support programme, it inevitably cannot be complete and there may have been valuable perspectives absent. Originality/value: The paper demonstrates that the analysis of facilitators and challenges with respect to the national support of implementation of integrated care initiatives should move beyond the focus on separate influencing factors and address the tensions that the complex interplay among these factors create. [ABSTRACT FROM AUTHOR]

Objectives: To examine the managerial behaviours adopted by commissioning managers in English primary care trusts (PCTs), and to explore the impact of these behaviours. Methods: Qualitative case studies were undertaken in four PCTs, focusing on staff engaged in the commissioning of hospital services. Both formal and informal observation were undertaken (150 hours), and 41 in-depth interviews conducted with managers and general practitioners (GPs). Results: Managers adopted many managerial behaviours familiar from the literature, including sharing information, and networking inside and outside the organization. Multiple organizational layers and unclear decision-making processes hindered this activity. In addition, some managers with responsibility for facilitating practice-based commissioning (PbC) adopted a managerial mode that we have called being an 'animateur'. This approach involved the active management of disparate groups of people over whom the manager had no authority, and appeared to be a factor in determining success. It was facilitated by managerial autonomy and was more prevalent where managers were seen to have legitimacy. Some organizational practices appeared to inhibit its development. Conclusions: From 2012/13 it is planned that GPs will be taking more responsibility for commissioning in the English NHS. This research suggests that managers of the new commissioning organizations will require a deep and contextualized understanding of the NHS and that it is important that organizational processes do not inhibit managerial behaviour. Legitimacymay be an issue in contexts were managers are automatically transferred from their existing appointments. [ABSTRACT FROM AUTHOR]