Leadership in the community sector: promoting collaboration and social change in Belfast

Community development is centrally concerned with people in communities working together to achieve a common goal, that is, to collaborate, whether within local geographical communities, in communities of shared interests or among groups sharing a common identity. Its overarching goal is one of progressive transformational social change. As Belfast transitions from a conflict to a post-conflict society, there is a need for greater, more effective work at local community level in order to address a range of ongoing social and economic issues facing communities, including high levels of disadvantage and division. Given the significance of leadership in building effective collaboration and the centrality of collaboration for community development, it is important to understand how leadership is currently enacted and what kinds of leadership are required to support communities to collaborate effectively to bring about social change. This thesis thus centers on the kind of leadership practised and required to support collaboration for social change within the community sector in Belfast, a city that contains an estimated 28% of the total number of community and voluntary sector (CVS) organisations in Northern Ireland (Northern Ireland Council for Voluntary Action, 2012). Through a series of qualitative, in-depth interviews with people playing leadership roles in local communities, the study critically explores and analyses their experiences and perceptions in relation to leadership and collaboration. Community development in Belfast today is practised within a wider context of neoliberal policies, characterised by austerity and public spending cuts. Whilst not the only influencing factor, this context has had a particular and profound impact on the nature and role of community development practised, and on the kind of leadership enacted within it. The space for reflection and transformative action appears to be shrinking as the contraction of resources to support community development in local communities continues unabated. Those playing leadership roles increasingly find themselves compelled to spend time seeking resources and managing complex funding arrangements rather than focusing on the social change dimensions of their work. Collaboration as promoted by the state seems to have become an instrumental tactic used to implement its austerity measures and curtail the potential of the community sector. Despite this, local leaders are driving initiatives that attempt to push back, helping the sector refocus on its transformational goals of social change. To do this requires support. Those playing leadership roles require resources, including time, to encourage and enable communities to reconnect with the purpose and underpinning values of community development. Leaders also need support to develop and promote new, progressive narratives and visions and pursue these through building collaboration and solidarity.

The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.