BackgroundHealth systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI).MethodsWe conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance.ResultsWe found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders.ConclusionsThis study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI.

This paper addresses shifting constructions of professional identity in the context of debates about reflexive modernisation and the changing role of professionals in the provision of primary healthcare. Data are drawn from interviews with 20 early-career general practitioners (GPs), who accounted for their orientations towards work in rather different ways from those typically reported in much primary care research. In particular, they reported high job satisfaction and success in achieving what they called 'nice work'. We argue that these GPs typify a shift in discourses of professionalism, characterised by respondents as the 'new general practice', which explicitly rejects many values attributed to 'traditional' general practice. Within the 'new general practice', professionalism has been de-coupled from some of the paradigmatic traits of traditional rhetorical accounts (such as vocation), and has significantly reframed others. Despite policy concerns that a retreat from 'vocational' professionalism will lead to reductions in service quality, we argue that this is not inevitable. The 'new general practice' resonates with the social values of reflexive modernisation, and has the potential to enable new, less paternalistic, forms of relationships with clients, although it remains to be seen whether this potential is realised in healthcare delivery.

This paper reports from an ethnographic study of hospital planning in England undertaken between 2006 and 2009. We explored how a policy to centralise hospital services was espoused in national policy documents, how this shifted over time and how it was translated in practice. We found that policy texts defined hospital planning as a clinical issue and framed decisions to close hospitals or hospital departments as based on the evidence and necessary to ensure safety. We interpreted this framing as a rhetorical strategy for implementing organisational change in the context of community resistance to service closure and a concomitant policy emphasising the importance of public and patient involvement in planning. Although the persuasive power of the framing was limited, a more insidious form of power was identified in the way the framing disguised the political nature of the issue by defining it as a clinical problem. We conclude by discussing how the clinical rationale constrains public participation in decisions about the delivery and organisation of healthcare and restricts the extent to which alternative courses of action can be considered.

BackgroundHealthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis’ typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England.MethodsWe conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents.ResultsTwo organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of ‘slack’—expressed by participants as the ‘space to think’ and ‘someone to do the doing’—and the presence of a functioning board.ConclusionsUnderperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.

Forms of large‐scale change, such as the regiona l re‐distribution of clinical services, are an enduring reform orthodoxy in health systems of high‐income countries. The topic is of relevance and importance to medical sociology because of the way that large‐scale change significantly disrupts and transforms therapeutic landscapes, relationships and practices. In this paper we review the literature on large‐scale change. We find that the literature is dominated by competing forms of knowledge, such as health services research, and show how sociology can contribute new and critical perspectives and insights on what is for many people a troubling issue.