In reviewing the four design process cases in chapters 7 and 8 we asked how they started, what the original scope was for the project, what kind of vision there was for the end product and how the project was governed and managed. A broad distinction can be made between the big vision for the project, e.g. introducing a new Frail Elderly Pathway (FEP) or a new centralized Diabetic Retinopathy Scanning Service and smaller scale projects such as the ‘refresh’ and ‘restart’ projects. The former are integrated systems developments often driven by national initiatives that have received additional funding. The latter are more likely to be scoped as developments of existing e-health systems defined as internal projects that receive no extra funding. We have labelled these top down and bottom up developments. In most instances the top down projects come before the bottom up ones but in the intermediate care case in Northamptonshire the internal ‘refresh’ project was underway before the top down CECS project intervened to send the informatics work in a different direction.
The top down projects that are big in scope were all initiated as a response to national imperatives. In the case of Diabetic Retinopathy Screening a key driver was a national framework for the delivery of this kind of screening linked to the organisational objective of creating a county-wide centralized service. Both the CECS and the FEP cases are responses to a national strategy to care for more of the frail elderly in the community and the Stroke Pathway at Walsall was a response to a national strategy for Stroke Care. In all these cases a dominant concern was to construct a process involving all the relevant agencies to achieve national performance targets and the scope of the project included process and organisational changes. In only one case, the Stroke Pathway in Walsall, was the creation of an e- health system (FUSION) one of the original drivers for the project. However, in all cases the vision for the project included an enhanced role for e-health systems. In all of these cases the scope of the projects and the vision for the planned outcomes involved multiple agencies, process redesign, organisational change and technical system development. Although it can only be inferred from the data, it is tempting to conjecture
that the concept of a healthcare pathway has helped to provide a multi- agency vision of the common objective.
The internal projects tended to be much more restricted in their scope, focused on technical system changes and limited to one or two agencies. They did, however, because they were based on changing an existing working system, deal with technical changes, process redesign and organisational issues in an integrated manner, albeit within a more limited arena.
The governance of the top down projects involved most or all of the agencies that contributed to the pathway at least in the initial stages. There was a conscious effort in Walsall, for example, to bring all the agencies together to discuss a future strategy for the care of the elderly before the FEP project was launched. And in all of the cases the vision for the project coalesced in the form of a business case to be put to the commissioners to obtain the resources to undertake the development work. We did not investigate this part of the overall process but it seems likely that, where agencies such as Social Services who are not part of the NHS are involved in these projects, they may have sought separate resources for the project. Whilst there is evidence for a broad based consensus for the policy-making stage of the big projects, the operational delivery of these developments was much more fragmented. It appears to have been very difficult for these projects to sustain an integrated delivery in which all the agencies and disciplines were involved in the process and in which process redesign, organisational changes and technical developments were kept together. There are, for example, no examples of an over-arching steering committee with membership from all agencies, guiding the project through all of its stages. It seems more likely that separate agencies and separate bodies within agencies take their part of the agenda and try to pursue it. In the Retinopathy case for example, the organisational changes appear to have taken place independently of the adoption of OptoMize. In the CECS case process and organisational changes also took place before e-health developments were considered. In the FEP case a deliberate attempt was made in the implementation plan to hold the different strands of the project together but the result was that the e-health developments lagged behind the other changes. Some of the difficulties of holding together a complex, multi-strand project can be gleaned from the FEP example where the creation of a body to engage with all the agencies through the implementation phase led to a ‘cast of thousands’ and what some concluded was a good talking shop but very poor at producing action. Other difficulties arise from the instability of organisational arrangements for the delivery of health and social care; during the course of this research there were re- organisations in the Trusts in the LHC and at the end of the research a further wave of changes were taking place. It can take some years to create a mature form of integrated care within a healthcare pathway and
organisational turbulence makes it more difficult to keep a stable framework in place.
There are some islands of maturity in the processes that these agencies regularly undertake; where new pathways and new e-health systems are required, for example, the processes of formulating business cases for review by commissioners is well established. There is also a degree of maturity in the way the different agencies in Walsall work together to formulate strategic plans for the borough. In a compact geographical area where agencies have co-terminus boundaries there has emerged over a period of years well-founded practices of working together on common concerns. The problems for both LHCs, however, is the immaturity of the practices of working together over the period of time necessary to deliver all the integrated care mechanisms necessary within a new health and social care pathway.