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Purpose: In this chapter, we examine the National Health Service (NHS) and Adult Social Care (ASC) in England, focussing on policies that have been introduced since 2000 and considering the challenges that providers face in their quest to provide a high standard and affordable health service in the near future.

Methodology/Approach: We discuss recent policy developments and published analysis covering innovations within major aspects of health care (primary, secondary and tertiary) and ASC, before considering future challenges faced by providers in England, highlighted by a 2017 UK Parliament Select Committee.

Findings: The NHS and ASC system have experienced tightening budgets and serious financial pressure, with historically low real-terms growth in health funding from central government and local authorities. Policymakers have tried to overcome these challenges with several policy innovations, but many still remain. With large-scale investment and reform, there is potential for the health and social care system to evolve into a modern service capable of dealing with the needs of an ageing population. However, if these challenges are not met, then it is set to continue struggling with a lack of appropriate facilities, an overstretched staff and a system not entirely appropriate for its patients.

This chapter presents an organizational learning approach to understanding the objectives and challenges of an National Health Service (NHS) Sustainable Development agenda, which involves the integration of social, ecological and economic concerns into organizational functioning, for example the construction and management of buildings, design and delivery of services, and employment of staff.

The approach is used to frame an empirical analysis of 11 Projects conducted by NHS organizations aiming to advance this agenda during a particularly active phase in the mid to late 2000s. The approach helps identify the assumptions of organizational purpose, strategy and practice inherent in proposals for Sustainable Development and expose the challenges these are likely to pose. This framing helps articulate a vision and identify the actor groups, and their guiding assumptions, which need to be engaged if progress is to be made.

The vision of Sustainable Development being promoted was predominantly one of an NHS contributing to the economic and social determinants of health through its procurement, service development and employment activities. Contributions to environmental determinants only took place where financial gains to the NHS organizations themselves made activities, such as investment in renewable energy, viable in the short-term. Within most Projects strategic tools able to predict and measure benefits had to be developed on-the-job and most received help from external agencies to do this work.

Rather than expecting individual NHS organizations to progress this agenda alone, others involved in the shaping of collective assumptions of the NHS' purpose and strategies for growth must be engaged in what can be viewed as a social process of learning.

The long-term plan for the National Health Service (NHS, 2019) identifies a blueprint to make the NHS fit for the future with a greater focus on prevention, improving services for patients and the importance of integrating services to make them more effective and efficient. The challenge is in the delivery and who is responsible to implement changes. The key is to enable staff at local levels to have responsibility for ensuring that the health and social needs of their local population are met.

Established to oversee the implementation is the NHS Assembly with 50 individuals from across the health and care sector to advise NHS England and NHS Improvement on the implementation. This requires shared commitment and motivation to change; ensuring patient centred care is at the forefront of any changes to delivering care. At regional level, Sustainability and Transformation Partnerships and Integrated Care Systems are groups of local NHS organisations, local councils and other partners, who are working together in the region to develop and implement the NHS plan. There are many challenges ahead to ensure the plan delivers better regional health and social care, including the impending UK’s decision to leave the European Union. Brexit may present some opportunities but if freedom of movement and membership of the single market and customs union end as planned, NHS and social care face several significant threats in the region.

A Memorandum of Understanding (MoU) was uncovered in January 2017 detailing the sharing of patient data from NHS Digital to the Home Office. It signified a deepening of the hostile environment’s presence in the NHS, and was comprehensively rejected by medical professionals. In November 2018, following extensive action calling for its removal, the MoU was withdrawn. This chapter explores how three factors: the lack of legal basis, wide reaching effects, and ethical conflicts of the MoU led to the success of this action, and aims to apply these lessons to other areas of hostile environment policy. It will be established that ethics proved the most influential factor in inciting the opposition, however, all factors may have been integral to the overall success. It shall be demonstrated that, although the success of this action promises much with regards to charging policy, it may be of limited applicability to other areas of the hostile environment.

Much has been made of economizing. Yet, social scientists have paid little attention to the moment of economic failure, the moments that precede it, and the calculative infrastructures and related processes through which both failing and failure are made operable. This chapter examines the shift from the economizing of the market economy, which took place across much of the nineteenth century, to the economizing and marketizing of the social sphere, which is still ongoing. The authors consider a specific case of the economizing of failure, namely the repeated attempts over more than a decade to create a failure regime for National Health Service (NHS) hospitals. These attempts commenced with the Health and Social Care Act 2003, which drew explicitly on the Insolvency Act 1986. This promised a “failure regime” for NHS Foundation Trusts modeled on the corporate sector. Shortly after the financial crash, and in the middle of one of the biggest scandals to face NHS hospitals, these proposals were abandoned in favor of a regime based initially on the notion of “de-authorization.” The notion of de-authorization was then itself abandoned, in favor of the notion of “unsustainable provider,” most recently also called the Trust Special Administrators regime. The authors suggest that these repeated attempts to devise a failure regime for NHS hospitals have lessons that go beyond the domain of health care, and that they highlight important issues concerning the role that “exit” models and associated calculative infrastructures may play in the economizing and regulating of public services and the social sphere more broadly.

High-quality nursing home (NH) care has long been a challenge within the United States. For decades, policymakers at the state and federal levels have adopted and implemented regulations to target critical components of NH care outcomes. Simultaneously, our delivery system continues to change the role of NHs in patient care. For example, more acute patients are cared for in NHs, and the Center for Medicare and Medicaid Services (CMS) has implemented value payment programs targeting NH settings. As a part of these growing pressures from the broader healthcare delivery system, the culture-change movement has emerged among NHs over the past two decades, prompting NHs to embody more person-centered care as well as promote settings which resemble someone's home, as opposed to institutionalized healthcare settings.

Researchers have linked culture change to high-quality outcomes and the ability to adapt and respond to the ever-changing pressures brought on by changes in our regulatory and delivery system. Making enduring culture change within organizations has long been a challenge and focus in NHs. Despite research suggesting that culture-change initiatives that promote greater resident-centered care are associated with several desirable patient outcomes, their adoption and implementation by NHs are resource intensive, and research has shown that NHs with high percentages of low-income residents are especially challenged to adopt these initiatives.

This chapter takes a novel approach to examine factors that impact the adoption of culture-change initiatives by assessing knowledge management and the role of knowledge management activities in promoting the adoption of innovative care delivery models among under-resourced NHs throughout the United States. Using primary data from a survey of NH administrators, we conducted logistic regression models to assess the relationship between knowledge management and the adoption of a culture-change initiative as well as whether these relationships were moderated by leadership and staffing stability. Our study found that NHs were more likely to adopt a culture-change initiative when they had more robust knowledge management activities. Moreover, knowledge management activities were particularly effective at promoting adoption in NHs that struggle with leadership and nursing staff instability. Our findings support the notion that knowledge management activities can help NHs acquire and mobilize informational resources to support the adoption of care delivery innovations, thus highlighting opportunities to more effectively target efforts to stimulate the adoption and spread of these initiatives.

On-going change in relation to the management of public services has led to the development of many initiatives in the control of day-to-day resources as the New Public Management¹ (Hood, 1991, 1995) continues its reforms. In this context debates about control of capital expenditure have taken a less visible role despite some earlier and influential comment on the area (Perrin, 1978 for example). Perhaps as the flow of ideas for reform in the management of day-to-day activity have waned, recent attention has turned more systematically to the efficient use of capital resources or infrastructure. This has been accompanied by recognition of the poor state of some of the public sector infrastructure. This chapter is concerned with the implications of the changing approaches to the provision of infrastructure is the U.K. National Health Service (NHS). Its particular focus in the Private Finance Initiative (PFI) and the contractual implications this brings into infrastructure development.

A policy of surveillance which interferes with the fundamental right to a private life requires credible justification and a supportive evidence base. The authority for such interference should be clearly detailed in law, overseen by a transparent process and not left to the vagaries of administrative discretion. If a state surveils those it governs and claims the interference to be in the public interest, then the evidence base on which that claim stands and the operative conception of public interest should be subject to critical examination. Unfortunately, there is an inconsistency in the regulatory burden associated with access to confidential patient information for non-health-related surveillance purposes and access for health-related surveillance or research purposes. This inconsistency represents a systemic weakness to inform or challenge an evidence-based policy of non-health-related surveillance. This inconsistency is unjustified and undermines the qualities recognised to be necessary to maintain a trustworthy confidential public health service. Taking the withdrawn Memorandum of Understanding (MoU) between NHS Digital and the Home Office as a worked example, this chapter demonstrates how the capacity of the law to constrain the arbitrary or unwarranted exercise of power through judicial review is not sufficient to level the playing field. The authors recommend ‘levelling up’ in procedural oversight, and adopting independent mechanisms equivalent to those adopted for establishing the operative conceptions of public interest in the context of health research to non-health-related surveillance purposes.

This chapter explains how fundamental organisational change in the UK National Health Service (NHS) is being effected by new practices of digitised information gathering and use. It analyses the taken-for-granted IT infrastructures that lie behind digitisation and considers the relationship between digitisation and big data.

Qualitative research methods including discourse analysis, ethnography of software and key informant interviews were used. Actor-network theories, as developed by Science and technology Studies (STS) researchers were used to inform the research questions, data gathering and analysis. The chapter focuses on the aftermath of legislation to change the organisation of the NHS.

The chapter shows the benefits of qualitative research into specific manifestations information technology. It explains how apparently ‘objective’ and ‘neutral’ quantitative data gathering and analysis is mediated by complex software practices. It considers the political power of claims that data is neutral.

The chapter provides insight into a specific case of healthcare data and. It makes explicit the role of politics and the State in digitisation and shows how STS approaches can be used to understand political and technological practice.