Chantler Tracey, Lwembe Saumu, Saliba Vanessa, Raj Thara, Mays Nicholas, Ramsay Mary, Mounier-Jack Sandra
London School of Hygiene & Tropical Medicine, Faculty of Public Health & Policy, London, UK.
Immunisation, Hepatitis & Blood Safety Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK.
BMC Health Serv Res. 2016 Sep 15;16:489. doi: 10.1186/s12913-016-1711-0.
The English health system experienced a large-scale reorganisation in April 2013. A national tri-partite delivery framework involving the Department of Health, NHS England and Public Health England was agreed and a new local operational model applied. Evidence about how health system re-organisations affect constituent public health programmes is sparse and focused on low and middle income countries. We conducted an in-depth analysis of how the English immunisation programme adapted to the April 2013 health system reorganisation, and what facilitated or hindered the delivery of immunisation services in this context.
A qualitative case study methodology involving interviews and observations at national and local level was applied. Three sites were selected to represent different localities, varying levels of immunisation coverage and a range of changes in governance. Study participants included 19 national decision-makers and 56 local implementers. Two rounds of interviews and observations (immunisation board/committee meetings) occurred between December 2014 and June 2015, and September and December 2015. Interviews were audio recorded and transcribed verbatim and written accounts of observed events compiled. Data was imported into NVIVO 10 and analysed thematically.
The new immunisation programme in the new health system was described as fragmented, and significant effort was expended to regroup. National tripartite arrangements required joint working and accountability; a shift from the simpler hierarchical pre-reform structure, typical of many public health programmes. New local inter-organisational arrangements resulted in ambiguity about organisational responsibilities and hindered data-sharing. Whilst making immunisation managers responsible for larger areas supported equitable resource distribution and strengthened service commissioning, it also reduced their ability to apply clinical expertise, support and evaluate immunisation providers' performance. Partnership working helped staff adapt, but the complexity of the health system hindered the development of consistent approaches for training and service evaluation.
The April 2013 health system reorganisation in England resulted in significant fragmentation in the way the immunisation programme was delivered. Some of this was a temporary by-product of organisational change, other more persistent challenges were intrinsic to the complex architecture of the new health system. Partnership working helped immunisation leaders and implementers reconnect and now the challenge is to assess how inter-agency collaboration can be strengthened.
英国卫生系统于2013年4月经历了大规模重组。涉及卫生部、英国国民医疗服务体系（NHS）英格兰分部和英国公共卫生部的全国三方交付框架达成一致，并应用了新的地方运营模式。关于卫生系统重组如何影响组成部分的公共卫生项目的证据很少，且主要集中在低收入和中等收入国家。我们对英国免疫规划如何适应2013年4月的卫生系统重组，以及在此背景下促进或阻碍免疫服务提供的因素进行了深入分析。
采用定性案例研究方法，包括在国家和地方层面进行访谈和观察。选择了三个地点，代表不同地区、不同免疫覆盖率水平以及一系列治理变化。研究参与者包括19名国家决策者和56名地方实施者。在2014年12月至2015年6月以及2015年9月至12月期间进行了两轮访谈和观察（免疫委员会会议）。访谈进行了录音并逐字转录，对观察到的事件编写了书面记录。数据导入NVIVO 10并进行主题分析。
新卫生系统中的新免疫规划被描述为碎片化，为此花费了大量精力进行重新整合。国家三方安排要求联合工作和问责；这与许多公共卫生项目典型的更简单的等级制改革前结构有所不同。新的地方组织间安排导致组织责任不明确，并阻碍了数据共享。虽然让免疫管理人员负责更大的区域有助于公平分配资源并加强服务委托，但这也降低了他们应用临床专业知识、支持和评估免疫提供者表现的能力。合作有助于工作人员适应，但卫生系统的复杂性阻碍了制定一致的培训和服务评估方法。
2013年4月英国卫生系统重组导致免疫规划的实施方式出现重大碎片化。其中一些是组织变革的临时副产品，其他更持久的挑战则是新卫生系统复杂架构所固有的。合作有助于免疫领导者和实施者重新建立联系，现在的挑战是评估如何加强机构间协作。
