SHOULD THE NATIONAL HEALTH SERVICE HAVE AN INFORMATION STRATEGY?

The National Health Service (NHS) Review committed the NHS to the development of sophisticated information management processes and to the creation of a massive information technology infrastructure, and the success of the new arrangements depends critically upon progress in these two areas. Yet the NHS has a modest track record in both, which the period since the review has served only to highlight. The article examines the political environment in which information is exchanged and technology implemented, in order to explain the current state of play and the likely pace and direction of future developments. In particular it focuses upon the role of the NHS Management Executive in influencing these developments, and argues that success will depend on the extent to which national information policies encourage collaboration between key groups of managers and professionals and support the implementation of contracts for health services.     

THE DYNAMICS OF PROFESSIONS AND DEVELOPMENT OF NEW ROLES IN PUBLIC SERVICES ORGANIZATIONS: THE CASE OF MODERN MATRONS IN THE ENGLISH NHS

This study contributes to research examining how professional autonomy and hierarchy impacts upon the implementation of policy designed to improve the quality of public services delivery through the introduction of new managerial roles. It is based on an empirical examination of a new role for nurses – modern matrons – who are expected by policy-makers to drive organizational change aimed at tackling health care acquired infections (HCAI) in the National Health Service (NHS) within England. First, we show that the changing role of nurses associated with their ongoing professionalization limits the influence of modern matrons over their own ranks in tackling HCAI. Second, the influence of modern matrons over doctors is limited. Third, government policy itself appears inconsistent in its support for the role of modern matrons. The attempts of modern matrons to tackle HCAI appear more effective where infection control activity is situated in professional practice and where modern matrons integrate aspirations for improved infection control within mainstream audit mechanisms in a health care organization.     

PUBLIC RESPONSIBILITY AND INEQUALITY IN HEALTH INSURANCE COVERAGE: AN EXAMINATION OF AMERICAN STATE HEALTH CARE SYSTEMS

This article examines the effect of the three publicness dimensions on inequality in health insurance coverage across 50 American state‐level health care systems. The analysis validates a Gini‐coefficient measure of Americans' unequal distribution of health insurance coverage across nine income groups and compares public ownership, financing, and control of health care systems across all 50 states from 2002 to 2010. There is a significant and negative relationship between public ownership and inequality in health insurance coverage, although the substantive impact of ownership is relatively small. Both public financing and control substantially reduce inequality in health insurance coverage across income groups. However, both of these must be present in order to be effective at reducing inequality. This article expands our understanding of the link between different institutional arrangements and inequality in health insurance coverage in hybrid health care systems.     

UNDERSTANDING CHANGE IN THE NHS

This paper presents a novel and distinctive approach to the study of change within the NHS. Central to the paper's approach is the view that research on change in health care systems should be processual, comparative, pluralist, and historically based. Guiding such a view is a meta-analytical framework which contends that theoretically sound and practically useful research on change should involve the continuous interplay between ideas about the context , the process , and the content of change together with skill in regulating the relations between the three (Pettigrew 1985a, 1985b). The paper has five sections. Section one examines some of the contemporary pressures for change in the NHS and draws attention to the gap which often exists between statements of strategic intention and their operational implementation. Section two reveals our distinctive analytical approach to the study of service changes and clarifies the theoretical underpinnings of our work. Section three offers an extended critical review of recent research and writing on change in health care organizations. Section four summarizes our findings from the literature review and reaffirms the novelty and significance of our chosen approach. Section five provides an overview.     

CONTRACTORS' EXPERIENCE OF COMPULSORY COMPETITIVE TENDERING: A CASE STUDY OF CONTRACT CLEANERS IN THE NHS

Compulsory competitive tendering (CCT) has been an important instrument of Conservative government economic policy since 1979. Its effectiveness in generating cost-effective services depends on competition to supply the service in question.
The NHS domestic market is large and, prior to the introduction of CCT, promised to be profitable for contractors. Many contract cleaners with office cleaning experience entered. In the event the costs of entry were heavy, and the profit margins of established firms were reduced. When contracts have been awarded to firms, they tended to be to those with a track record. Many firms therefore withdrew; and the few that remained have profit margins in the NHS little different from those found elsewhere. Of more than by firms with a serious interest in entry, probably no more than a handful can have come out of the experience in net profit in the first seven years.
The experience of CCT in the market for NHS domestic services has shown that a degree of competition in the market can be achieved, arguably because of the presence of direct service organizations. Competition for this market, on the other hand, can be limited by the high costs of entry.     

PRESCRIPTIONS FOR REGIONAL ECONOMIC DILEMMAS: UNDERSTANDING THE ROLE OF THINK TANKS IN THE GOVERNANCE OF REGIONAL POLICY

The aim of this paper is to contribute to the understanding of the role of think tanks in the governance of regional policy. The paper critically reviews a series of reports by United Kingdom (UK) based think tanks, published between 2002 and 2008, a period of interest on the part of national government in the most appropriate configuration of subnational governance. Policy transfer and the role of ideas in regional policy provide the framework for analysis. The interpretation of the findings suggests that the think tanks considered are largely products of national policy debate and party politics in the United Kingdom, despite efforts to devolve power. This is surprising given debates about the influence of European Union regional funding on UK regional policy, seen as a prime example of multi‐level governance.     

POLICY AS NARRATIVE: NEW LABOUR’S REFORM OF THE NATIONAL HEALTH SERVICE

Beginning with a brief review of the governance literature, a definition of governance in the National Health Service of England and Wales (NHS) is offered. This introduces an analysis of NHS reform, as presented in the recent policy literature. Using narrative theory, I critique this literature with reference to three key actors: the new organizational form of the ‘Foundation Trust’, NHS staff, and NHS patients. For each actor, a motif is identified and examined: ‘freedom’ for Foundation Trusts, ‘clinical governance’ for staff, and ‘choice’ for patients. Each of these motifs is instrumental in the narrative on NHS reform, whose main themes are emancipation, progress and duty. These are common to other political projects. This critique makes the rhetoric underpinning the recent policy literature more explicit, and underlines the created, contingent nature of New Labour’s account of NHS reform.     

THE CONDITIONS FOR HEALTH AND SOCIAL CARE POLICY: ROUTINES AND INSTITUTIONS IN THE DUTCH CASE OF NEED ASSESSMENT

By focusing on institutions (rules for action) and routines (patterned behaviour) our intention is to contribute to the understanding of government policy and its outcomes in health and social care. We analysed data to show how the relationship between a new idea for a routine and new rules from the government on the one hand, and existing rules and routines in society on the other, as well as the interaction between rule makers and rule takers (i.e. those who are governed by those rules), have an impact on the change or maintenance of routines. The data concern the case of government policy for need assessment (that is, assessment of needs) in The Netherlands. As our discussion will show, even a national government, however, is not able to completely impose its will on other agents in order to change existing routines. The concept of ‘negotiated order’ helps us to understand why. In the case reported here, the Dutch government and the home care agencies had to exercise give and take, the outcome being a suboptimal result for both.     

Voice and choice in health care in England: understanding citizen responses to dissatisfaction

Using data from a five-year online survey the paper examines the effects of relative satisfaction with health services on individuals' voice-and-choice activity in the English public health care system. Voice is considered in three parts – individual voice (complaints), collective voice voting and participation (collective action). Exercising choice is seen in terms of complete exit (not using health care), internal exit (choosing another public service provider) and private exit (using private health care). The interaction of satisfaction and forms of voice and choice are analysed over time. Both voice and choice are correlated with dissatisfaction with those who are unhappy with the NHS more likely to privately voice and to plan to take up private health care. Those unable to choose private provision are likely to use private voice. These factors are not affected by items associated with social capital – indeed, being more trusting leads to lower voice activity.     

MEASURING NEED IN THE NATIONAL HEALTH SERVICE RESOURCE ALLOCATION FORMULA: STANDARDIZED MORTALITY RATIOS OR SOCIAL DEPRIVATION?

All methods of dividing public expenditure between competing claims become contentious, particularly when they rely on social indicators of need. The Resource Allocation Working Party (RAW) formula devised in 1976 for distributing National Health Service financial resources fairly between different parts of England relies on the size, age/sex structure and mortality rates (in the form of standardized mortality ratios – SMRS) of populations as combined surrogates for their need for health care. This paper aims to demonstrate three things: first, that RAW'S approach in selecting SMRS was sure-footed; second, that no better proxy of health care need which could be used in RAW has been produced since RAW; and third, that the continuing criticism of SMRS has been sustained by political pressures within the NHS. The result has been the application of ever more indirect and complex surrogates for'need in the resource allocation process which are known to be contaminated by the prevailing unequal supply of health service facilities.     

Increasing income inequality and wealth concentration in the prosperous societies of the west

Since about 1980, personal income and wealth inequality in many western societies has increased. This is a reversal of the trend of diminishing socioeconomic inequality during the larger part of the twentieth century. Both trends are explained by relating them to the long-term growth of networks of interdependence. When and insofar as the development predominantly took place within national states, it led to the diminution of power differences between socioeconomic classes. In recent years, however, transnational relations of interdependence have intensified to such a degree that they bring about a weakening of interdependence within national states and increase inequality. Nico Wilterdink teaches sociology at the University of Amsterdam, the Netherlands. He also occupies the Norbert Elias chair in social sciences at Utrecht University.     

Joining it up? Health and Wellbeing Boards in English Local Governance: Evidence from Clinical Commissioning Groups and Shadow Health and Wellbeing Boards

Statutory responsibility for health care and social care has long been separated between National Health Service (NHS) bodies and local government authorities. Repeated policy attempts to promote service integration through collaboration between such authorities have achieved little. The latest of such policy interventions are the Health and Wellbeing Boards (HWBs) established by the 2012 Health and Social Care Act (HSCA) alongside a range of other organisational innovations, including Clinical Commissioning Groups (CCGs). These organisations await full legal and operational status but have begun to develop structures and processes. HWBs are intended to lead the integrated assessment of local needs to inform both NHS health and local authority social care commissioners. We undertook detailed qualitative case studies in eight CCGs during 2011–2012 and here report observational and interview data related to CCGs’ perspectives and observations of early HWB developments. We found that developing HWBs vary greatly in their structure and approach, but we also identified a number of significant issues that are familiar from earlier research into health and social care integration. These include heavy dependence on voluntary agreements to align the strategic plans of the many different new statutory bodies; a significant role for mundane organisational processes in determining the extent of effective co-operation; and problems arising from factors such as size and the arrangements of local boundaries.     

CONSULTATIVE PROCESSES IN HEALTH POLICY IN THE UNITED KINGDOM: A VIEW FROM THE CENTRE

Health policy at national level is the product of a series of continuous and complex interactions between interest groups operating both inside and outside government. It is generally thought that these consultative processes are closed, elitist and dominated by the prestigious medical specialties. Yet there has been a rapid growth in the number of groups representing various interests, professions and care groups. Drawing on recent examples from the national health service, the paper explores the extent to which consultative processes in health policy have remained closed or have been opened up to new influences. The analysis suggests that consultation within the health department is more pluralistic than is usually appreciated. Also, while the closed, elitist mode of consultation with external interests has been eroded marginally, it remains more or less intact. Nevertheless, the ability of powerful medical interests to get their own way to the exclusion of other interests depends on the resources and sanctions available to other groups and on the particular policy issue. It can no longer just be assumed.     

Health care reform in Israel: An historical and sociopolitical conundrum

A new and comprehensive National Health Insurance Law was implemented in Israel on January 1, 1995. This major health care reform initiative culminated an effort lasting several decades to assure broad universal health care coverage for the population as a matter of national law. Issues that affected the development of the reform package included 1) the formation of sick funds that provide care to over 96% of the population as part of other powerful sociopolitical organizations, 2) the historical development of parallel private July 16, 1995 and governmental health care systems before Israel became a state in 1948 and the post-state maintenance of multiple health care delivery systems, and 3) the close interactions of health care systems and the political processes and parties of the nation. This paper describes the effects of these forces on resisting changes that were widely accepted as being necessary to expand access, control rising health care costs, and improve the efficiency of the nation's health care system.     

THE THEORY AND PRACTICE OF MANAGED COMPETITION IN THE NATIONAL HEALTH SERVICE

This article presents qualitative and survey evidence on the implementation of managed competition in the NHS. After outlining the economic analysis of quasi-markets made by Le Grand and Bartlett, Part I argues that a framework derived from organization theory is a more fruitful way of analysing and understanding behaviour at local level. Part II describes the experience of implementation in four district health authorities, concentrating on the way key actors conceptualized market relations and the way market imperfections were addressed. Part III discusses the main reasons why implementation took the form it did and the factors shaping similar or dissimilar responses.     

EVIDENCE‐BASED MANAGEMENT: THE VERY IDEA

This essay critically evaluates the recent phenomenon of ‘evidence‐based management’ in public services that is especially prominent in health care. We suggest that the current approach, broadly informed by evidence‐based health care, is misguided given the deeply contested nature of ‘evidence’ within the discipline of management studies. We argue that its growing popularity in spite of the theoretical problems it faces can be understood primarily as a function of the interests served by the universalization of certain forms of managerialist ‘evidence’ rather than any contribution to organizational effectiveness. Indeed, in a reading informed by the work of French geographer Henri Lefebvre, we suggest that in the long term the project is likely to inhibit rather than encourage a fuller understanding of the nature of public services. We conclude with a call for forms of organizational research that the current preoccupations of the evidence‐based project marginalize if not write out altogether.     

MEMBERSHIP OF THE ‘NEW STYLE’ HEALTH AUTHORITIES: CONTINUITY OR CHANGE?

The 1989 White Paper 'Working for Patients' continued the process begun by Griffiths of managerial reform and the introduction of private sector concepts into the NHS. One of the new proposals was to change the composition and constitution of health authorities, both to avoid the assumed weaknesses of the existing format and to emulate the pattern found in the private sector.
The essence of the change was the removal of the representational elements on authorities, both of medical professionals and nominees from the local authority. The health authorities were reduced in size to just eleven members and for the first time executives were included. Previous attempts at reform within the NHS have been judged to have resulted in more continuity than change. This article examines in detail who the new members are and assesses the balance between continuity and change.
Despite a high level of continuity of membership, there are signs of more fundamental change. There is a significant increase in the proportion of non-executive members from the private sector and with the inclusion of executives, a stronger managerial role is emerging. The article concludes by assessing what the implications of these changes maybe.     

THE QUASI-MARKET,THE ENTREPRENEUR AND THE EFFECTIVENESS OF THE NHS BUSINESS MANAGER

The recent changes in the UK National Health Service were heralded by the publication of the Griffiths report in 1983 which highlighted the need for a business-like’approach to management. The policy makers’generic strategy of the late 1980s and early 1990s centred around the concept of‘quasi-markets’. These were artificial internal markets encompassing the purchasers and providers of public services. Little research has been undertaken into this new phenomenon of the‘quasi-market’but entrepreneurship economic theory would suggest that for markets to be efficient would require a supply of alert and aware entrepreneurs. Within the restructured NHS, the mantle for entrepreneurial management seems to have been placed firmly on the shoulders of the newly created‘business managers’. A 1993 survey amongst NHS business managers in first and second wave trust hospitals in the Trent Regional Health Authority indicated that whilst business managers were knowledgable of what entrepreneurial activity is, they currently feel constrained in their new roles for a variety of reasons. The authors suggest that rational economic analysis is insufficient to explain this lack of innovatory endeavour. Instead policy makers’attention should be devoted to liberating health managers from their current constraints to encourage their entrepreneurial development.     

DEVELOPMENTS IN THE PURCHASING PROCESS IN THE NHS: TOWARDS AN EXPLICIT POLITICS OF RATIONING?

The introduction of the internal market to the National Health Service in Britain marks a major change in the form of provision of health care interventions. This article reports the findings of independent research into the development of the purchasing process in eight purchasing authorities (which collectively purchase health care for 5 per cent of the population of Britain), and considers the extent to which this has led to an explicit politics of rationing in British health care. The structure and organization of purchasing organizations is described, along with their relationship with providers of health care. The ability of purchasing organizations to assess the health needs of the populations for which they purchase health care services, and their ability to influence change in the nature of the services provided, is also examined.     

A pilot study of the suicide victim's last contact with a health professional

Suicide victims frequently have contact with health care professionals in the months before death. The primary aims of this pilot psychological autopsy study were to determine the feasibility of undertaking a full study and to describe the characteristics of the last health care professional contacts with suicide victims aged > 34 years. We interviewed the informants of 52 suicides. Interviews were obtained from 37 health care professionals who had contact with 28 of the suicides during the 3 months before death. The primary reasons for the last contact with the health care professional were mental health (62%), physical health (22%), and social (14%). 87% of health care professional contacts occurred within 1 month of death. Symptoms of depression were noted in 49% of health care professional contacts. Consensus psychological autopsy diagnoses of depression were made in 64% of suicide victims. Overall suicide risk was assessed by 38% of health care professionals during their last contact. This was more likely to occur when the deceased presented as depressed, was aged < 60 years or seen by a psychiatrist. None was assessed to be suicidal. The family informants regarded nine of the suicide victims to have been suicidal before death but informed a health care professional in only one third of the cases. Critical information that might have altered the management is not often accessed from family members.