CAPÍTULO 1. Los microcontroladores PICs El PIC 16F877A
1.3 Subsistemas avanzados en el PIC 16F877A
1.3.2 Interfaz de conversión análogo digital (CAD)
A common criticism of case studies, even when there as many as we sampled, is their uniqueness and their‘generalisability’. Although we attempted to elicit a representative sample of CCG-led commissioning networks for study, they proved difficult to access and many of the initial agreements for access fell through as key personnel acting as gatekeepers changed, as we were passed on to other staff who were to operationalise the study and as staff in CCGs came under increasing work pressures. Therefore, some readers might judge our sample of case studies as less representative along other dimensions of commissioning networks; for example, given the empirical tracer of elderly care, we might have sampled for population demographics. Nevertheless, we have attempted to generate transferable lessons for other commissioning networks through theoretical analysis, drawing on dimensions of ACAP to highlight factors influencing knowledge mobilisation.
Similarly, as revealed in our table of interviewees, although managerial staff engaged with our research, accessing GPs proved more challenging. Of all commissioning stakeholders, they are subject to the greatest work pressures, particularly when they undertake hybrid roles combining commissioning and clinical responsibilities. We thank those GPs in particular who gave up their valuable time to participate in our study. However, given the variable influence of different groups of GPs revealed within our empirical analysis, we encourage others to engage in more specific study of GP involvement in commissioning
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TABLE 3 Example of coding structure
CCG
characteristic Systems Socialisation Co-ordination
GP involvement Trying to find out what the CCG wanted of us and whether I thought that was what I could deliver for them . . . To be honest, there was quite a lot of uncertainty about what they wanted me to do here . . . they didn’t seem to know what to do with me at first
CCG L, interview 4
There is still a problem for them in that there are still people in the system who are old PCT SHA staff so still see themselves as the old PCT SHA sort of‘You’ll do what I say’type, but I actually think that’s probably improving
CCG H, interview 4
If you get buy-in from the GPs it’s a lot easier to get the service running. And they can tell you whether it will work or not, where the problems might be. So that’s always important
CCG I, interview 3
BI We no longer have that data coming directly to us, therefore we have to access it from the CSU, the Clinical Support Unit, and quite often we have sort of . . . Prior to my coming here there was a list of data which it was agreed we would have access to regularly. My understanding is that we are not always being given access to the data that we require from the CSU and I’m not entirely sure why that is. I’m actually waiting for a phone call. Someone was supposed to phone me yesterday so we’d have the conversation about what’s happening. Our access to data is currently quite limited
CCG M, interview 5
I think it’s very easy to become just an analyst where you’re just this is the process, there’s the number, churn the numbers out, give them an overarching this is how we’ve got to the numbers, but then to understand the question that they’ve asked in the first place you probably need to be there to react to what they react to when they see that number in front of them
CCG M, interview 9
They started from the fact that they’ve got a single acute provider working across two sites with basically unsustainable services, in their view, into the long term because of insufficient capacity. So they wanted to run a reconfiguration programme to design a new clinical model for that patch and then out of that clinical model to run all the processes necessary to try to identify a preferred option for reshaping their hospital system . . . now we’re helping them design their primary care strategy, their community services strategy and helping them properly work out what the implications are for primary care, community care, social care, mental health services of their intended shift of activity out of the acute sector, which is the bit that everyone struggles to do CCG M, interview 12 continued HEALTH SERVICES AND DELIVERY RESEARCH 2018 VOL. 6 NO. 12 and Controller of HMSO 2018. This work was produced by Currie et al. under the terms of a commissioning contract issued by the Secretary of State for Health This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be incl uded in professional that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for comme rcial reproduction should to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, U niversity of Southampton Science SO16 7NS, UK.
TABLE 3 Example of coding structure (continued)
CCG
characteristic Systems Socialisation Co-ordination
Integrated teams
I think we’re quite advanced in recording of information, but generally community services are quite poor at really understanding what their services are and what they cost and how they’re delivered
CCG G, interview 10
It was complicated before the reforms; now it is just . . . it’s unworkable and we’re seeing this with cancer, we’re seeing it with specialised commissioning, we’re seeing it with general practice. It’s just bonkers the current system. Fragmentation along relatively arbitrary lines denies the complex interrelationships between the components of delivery of good care. The fragmentation between health and social care was bad enough and now we’ve broken health care up you’ve probably got seven different players pulling bits of the service in different directions to meet their own requirements and of course the person who gets left in the gap is the patient
CCG J, interview 7
So the idea of the [integrated team] is to be multiprofessional. So you’ve got clinicians, commissioners, service providers, researchers . . . Not the voluntary sector if I’m honest, although we’ve got good contacts building with the voluntary sector, but we’ve got representation from all those groups, so when the team discuss a problem you’ve got all those voices around the table which I think is what makes it quite unique
CCG K, interview 5
PPI Our patients have been telling us, if people had had their ears open, that care was unsatisfactory for a long time, but we’ve chosen or not been able to for various reasons to listen to and respond to that
CCG C, interview 8
There’s no culture within the health service’s or GPs’way of looking at the world that has a link with local communities apart from say the GP. They don’t go out. There’s no outreach and that sort of thing. So there’s not a culture first of all, but I think they would like there to be one. You see, I think they would like there to be, but at the moment I can only see it as something that they aren’t giving enough priority to
CCG G, interview 2
That’s where I think our biggest influence can be. We think out of the box. We’re not restrained and tied and if somebody says‘Oh, you can’t do that.’ ‘Why?’We won’t accept the restraints.‘Oh, you can’t do that because of such and such.’ ‘Well let’s change it then.’And people are saying‘We haven’t looked at it like that. We haven’t thought about it like that,’but as lay people we will and I think that is the best thing
CCG A, interview 7
SHA, Strategic Health Authority.
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to ascertain if this has spread beyond a narrow cadre of GPs who engaged similarly with previous arrangements under PCTs.
At the inception of our study, CCGs were fledgling organisations. As highlighted in empirical analysis, the development of social and organisational relationships across the commissioning network takes time. Our study only partially revealed this given the limited time period over which we undertook data collection. Others may follow our study, perhaps revealing the development of critical review capacity of CCGs as their relationships developed across the commissioning network.