Tim Tenbensel

Introduction: Why do integrated care programmes succeed in some settings but not others, even when national leadership and funding are aligned? This persistent question shaped our examination of the New Zealand Falls and Fracture Prevention Programme (FFPP), a complex, cross-sector initiative targeting older adults. We applied and extended the Context and Capabilities for Integrating Care (CCIC) framework to explore how organisational and inter-organisational factors contributed to variation in implementation and outcomes. Method: We conducted a qualitative comparative case study of four large districts with differences in FFPP implementation including 28 semi-structured interviews. Thematic analysis was primarily deductive, using the CCIC framework, but remained open to emergent, context-specific themes. Results: We identified 43 organisational and implementation factors, of which five had a particularly important effect on FFPP implementation and outcomes: a well-structured governance team, collaborative leadership, engagement with primary care and private organisations, positive prior collaboration experience, and applying a population-based approach. We modified the CCIC framework to more fully reflect our observations by adding prior collaboration experience and a life-cycle approach (from pre-engagement to establishment). Conclusion: The CCIC framework captured most key organisational dynamics but was enhanced by incorporating temporal and historical dimensions of collaboration.

Background: Falls among older people are a major cause of the global burden of disease. This study investigated the implementation of the Falls and Fracture Prevention Programme, a multicomponent population-based intervention, across diverse districts in New Zealand. Methods: We conducted a comparative case study through 28 semi-structured interviews with programme coordinators and managers across four districts. Transcripts were analysed using the programme framework, focusing on the implementation and outcomes of three primary components: Community Strength and Balance, In-Home Strength and Balance and Fracture Liaison Service. Results: We found both similarities and differences in the implementation of the programme’s components. All districts successfully engaged community providers to deliver accredited group exercises for Community Strength and Balance, though there were variations in human resources and community awareness of sessions. In-Home Strength and Balance implementation differed, affecting attendance, with successful implementation linked to empowering private physiotherapy organisations; however, funding withdrawal raised sustainability concerns. Variations in the Fracture Liaison Service implementation underscored inconsistencies in patient identification, highlighting the importance of primary care engagement and standardised protocols. Primary care involvement across all components was essential for successful implementation, and districts with higher primary care engagement and well-planned awareness sessions reported increased patient attendance. Conclusions: Overall, effective screening, primary care engagement and collaboration with private organisations and community providers were vital for the successful implementation of this population-based falls prevention programme.

Clinical indicators are increasingly used to improve the quality of care, particularly with the emergence of ‘big data’, but physicians’ views regarding their utility in practice is unclear. We reviewed the published literature investigating physicians’ perspectives, focusing on the following objectives in relation to quality improvement: (1) the role of clinical indicators, (2) what is needed to strengthen them, (3) their key attributes, and (4) the best tool(s) for assessing their quality. A systematic literature search (up to November 2022) was carried out using: Medline, EMBASE, Scopus, CINAHL, PsycInfo, and Web of Science. Articles that met all of the following inclusion criteria were included: reported on physicians’ perspectives on clinical indicators and/or tools for assessing the quality of clinical indicators, addressing at least one of the four review objectives; the clinical indicators related to care at least partially delivered by physicians; and published in a peer-reviewed journal. Data extracted from eligible studies were appraised using the Critical Appraisal Skills Programme tool. A thematic synthesis of data was conducted using NVivo software. Descriptive themes were inductively derived from codes, which were grouped into analytical themes answering each objective. A total of 14 studies were included, with 17 analytical themes identified for objectives 1–3 and no data identified for objective 4. Results showed that indicators can play an important motivating role for physicians to improve the quality of care and show where changes need to be made. For indicators to be effective, physicians should be involved in indicator development, recording relevant data should be straightforward, indicator feedback must be meaningful to physicians, and clinical teams need to be adequately resourced to act on findings. Effective indicators need to focus on the most important areas for quality improvement, be consistent with good medical care, and measure aspects of care within the control of physicians. Studies cautioned against using indicators primarily as punitive measures, and there were concerns that an overreliance on indicators can lead to narrowed perspective of quality of care. This review identifies facilitators and barriers to meaningfully engaging physicians in developing and using clinical indicators to improve the quality of healthcare.

Introduction: Within primary health care policy, there is an increasing focus on enhancing involvement with secondary health care, social care services and communities. Yet, translating these expectations into tangible changes frequently encounters significant obstacles. As part of an investigation into the progress made in achieving primary health care reform in Aotearoa New Zealand, realist research was undertaken with those charged with responsibility for national and local policies. The specific analysis in this paper probes primary health care leaders’ assessments of progress towards more collaboration with other health and non-health agencies, and communities. Aim: This study aimed to investigate how ideas for more integration and joinedup care have found their way into the practice of primary health care in Aotearoa New Zealand. Methods: Applying a realist logic of inquiry, data from semi-structured interviews with primary health care leaders were analysed to identify key contextual characteristics and mechanisms. Explanations were developed of what influenced leaders to invest energy in joined-up and integrated care activities. Results: Our findings highlight three explanatory mechanisms and their associated contexts: a willingness to share power, build trusting relationships and manage task complexity. These underpin leaders’ accounts of the success (or otherwise) of collaborative arrangements. Discussion: Such insights have import in the context of the current health reforms for stakeholders charged with developing local approaches to the planning and delivery of health services.

Research on governance often assumes that governance requires combinations of hierarchical, market and network co-ordination. However, governance versatility – understood as the existence of a repertoire of different modes of coordination – is not a characteristic of all instances of governance. The aim of this paper is to offer a more thorough analysis by exploring existing levels of governance versatility and how these are influenced by institutional profiles. Our comparative study of primary care performance across six jurisdictions suggests that higher levels of governance versatility can be shaped by very different institutional profiles. Our analysis raises important questions for future studies of governance versatility.