title: Stimulating whole system redesign: Lessons from an organizational analysis of the Whole System Demonstrator programme.
abstract: OBJECTIVE
  Whole system integration of health and social care has been positioned as key to improving care, increasing efficiency and controlling costs. However, evidence for the benefits of whole system integration is scarce. Drawing on organizational theory, this study uses the implementation of remote care services, viewed as an enabler for whole system working, to explore the reality of achieving this policy objective.
  
  
  METHODS
  Qualitative, longitudinal data were collected across nine UK sites adopting remote care over three years. Three sites formed the Department of Health's Whole Systems Demonstrator (WSD) programme for remote care. In addition, the implementation of remote care was explored in six other sites unconstrained by the randomized control trial procedures of the WSD programme. The methods were ethnographic (including 235 hours of observations and 184 interviews). Participants were health and social care staff and Government policy makers.
  
  
  RESULTS
  Remote care did not lead to system redesign; however, local 'ownership' of new services did lead to more collaborative practices across the care system. Lack of integration was an enduring and endemic challenge across all sites, relating to differences in statutory responsibilities, absence of shared budgets and hybrid organizational roles, differences in work practices and organizational philosophies, and ambiguity around what 'whole system working' actually entailed.
  
  
  CONCLUSIONS
  Policy initiatives like the WSD programme provide opportunities to phase in collaborative practices and create an awareness of the need for joint working. However, the progress observed suggests that the concept of whole system redesign around remote care is currently unrealistic.
authors.affiliation: Research Associate, Healthcare Management Group, Imperial College, Business School, Imperial College, London, UK t.chrysanthaki@imperial.ac.uk.
authors.forename: Theopisti
authors.initials: T
authors.lastname: Chrysanthaki
authors.affiliation: Senior Lecturer in Health Care Management, Department of Health Care Management and Policy, University of Surrey, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Hendy
authors.affiliation: Professor of Technology and Innovation Management, Imperial College Business School, Imperial College, London, UK.
authors.forename: James
authors.initials: J
authors.lastname: Barlow
mesh_terms: D006291:Health Policy; D006801:Humans; D019982:Organizational Case Studies; D009936:Organizational Innovation; D016032:Randomized Controlled Trials as Topic; D017216:Telemedicine
keywords: implementation; remote care; whole system working