title: Mind the gap between policy imperatives and service provision: a qualitative study of the process of respiratory service development in England and Wales.
abstract: BACKGROUND
  Healthcare systems globally are reconfiguring to address the needs of people with long-term conditions such as respiratory disease. Primary Care Organisations (PCOs) in England and Wales are charged with the task of developing cost-effective patient-centred local models of care. We aimed to investigate how PCOs in England and Wales are reconfiguring their workforce to develop respiratory services, and the background factors influencing service redesign.
  
  
  METHODS
  Semi-structured qualitative telephone interviews with the person(s) responsible for driving respiratory service reconfiguration in a purposive sample of 30 PCOs. Interviews were recorded, transcribed, coded and thematically analysed.
  
  
  RESULTS
  We interviewed representatives of 30 PCOs with diverse demographic profiles planning a range of models of care. Although the primary driver was consistently identified as the need to respond to a central policy to shift the delivery of care for people with long-term conditions into the community whilst achieving financial balance, the design and implementation of services were subject to a broad range of local, and at times serendipitous, influences. The focus was almost exclusively on the complex needs of patients at the top of the long-term conditions (LTC) pyramid, with the aim of reducing admissions. Whilst some PCOs seemed able to develop innovative care despite uncertainty and financial restrictions, most highlighted many barriers to progress, describing initiatives suddenly shelved for lack of money, progress impeded by reluctant clinicians, plans thwarted by conflicting policies and a PCO workforce demoralised by job insecurity.
  
  
  CONCLUSIONS
  For many of our interviewees there was a large gap between central policy rhetoric driving workforce change, and the practical reality of implementing change within PCOs when faced with the challenges of limited resources, diverse professional attitudes and an uncertain organisational context. Research should concentrate on understanding these complex dynamics in order to inform the policymakers, commissioners, health service managers and professionals.
authors.affiliation: Allergy & Respiratory Research Group, Centre of Population Health Sciences: GP Section, University of Edinburgh, 20 West Richmond St, Edinburgh EH89DX, UK. sonyahamilton@gmail.com
authors.forename: Sonya
authors.initials: S
authors.lastname: Hamilton
authors.forename: Guro
authors.initials: G
authors.lastname: Huby
authors.forename: Alison
authors.initials: A
authors.lastname: Tierney
authors.forename: Alison
authors.initials: A
authors.lastname: Powell
authors.forename: Tara
authors.initials: T
authors.lastname: Kielmann
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
authors.forename: Hilary
authors.initials: H
authors.lastname: Pinnock
mesh_terms: D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000592:standards; D004739:England; D006801:Humans; D007407:Interviews as Topic; D008134:Long-Term Care; D009936:Organizational Innovation; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy; D012017:Referral and Consultation; D012138:Respiratory Therapy / Q000592:standards*; D014852:Wales