In addition to introducing markets and market-like structures into public services, New Labour wished to promote the involvement of users and the public in decision-making in other ways than as individual consumers. One way was to involve the public in the governance of organizations. This could be done by removing public services from state control, and transferring them to mutual ownership; or by increasing public involvement in the governance of public bodies. NHS foundation trusts (FTs) were presented as mutuals. Our study shows FTs are not mutuals, as they continue to be owned by the state. Moreover, staff of FTs were generally not engaging with the new governance structures. In general, there was mixed experience of the new structures enabling governors to increase accountability of the hospitals to the public. On the other hand, having a membership did enhance the legitimacy of FTs, as opposed to other NHS organizations. The findings of the study are of current interest as the coalition government is continuing with the policy of FTs, and also encouraging mutuals and other forms of public involvement.

Organizational Form as a Mechanism to Involve Staff, Public and Users in Public Services: A Study of the Governance of NHS Foundation Trusts

This paper aims to probe the differences between the United Kingdom's four separate health systems. These systems, it argues, are diverging in terms of structures, management approaches, and the way social care relates to health.

https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_summary/four-uk-health-systems-jun13.pdf

The Four UK Health Systems: Learning from Each Other

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK-wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro-level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.

/pdf/devolution-and-patient-choice-policy-rhetoric-versus-2svzeqgx3k.pdf

Devolution and Patient Choice: Policy Rhetoric versus Experience in Practice

Background The task of matching fluctuating demand with available capacity is one of the basic challenges in all large-scale service industries. It is a particularly pressing concern in modern health-care systems, as increasing demand (ageing populations, availability of new treatments, increased patient knowledge, etc.) meets stagnating supply (capacity and funding restrictions on staff and services, etc.). As a consequence, a very large portfolio of demand management strategies has developed based on quite different assumptions about the source of the problem and about the means of its resolution. Methods This report presents a substantial review of the effectiveness of main strategies designed to alleviate demand pressures in the area of planned care. The study commences with an overview of the key ideas about the genesis of demand and capacity problems for health services. Many different diagnoses were uncovered: fluctuating demand meeting stationary capacity; turf protection between different providers; social rather than clinical pressures on referral decisions; self-propelling diagnostic cascades; supplier-induced demand; demographic pressures on treatment; and the informed patient and demand inflation. We then conducted a review of the key ideas (programme theories) underlying interventions designed to address demand imbalance. We discovered that there was no close alignment between purported problems and advocated solutions. Demand management interventions take their starting point in seeking reforms at the levels of strategic decision-making, organisational re-engineering, procedural modifications and behavioural change. In mapping the ideas for reform, we also noted a tendency for programme theories to become ‘whole-system’ models; over time policy-makers have advocated the need for concerted action on all of these fronts. Findings The remainder and core of the report contains a realist synthesis of the empirical evidence on the effectiveness on a spanning subset of four major demand management interventions: referral management centres (RMCs); using general practitioners with special interests (GPwSIs) at the interface between primary and secondary care; general practitioner (GP) direct access to clinical tests; and referral guidelines. In all cases we encountered a chequered pattern of success and failure. The primary literature is replete with accounts of unanticipated problems and unintended effects. These programmes ‘work’ only in highly circumscribed conditions. To give brief examples, we found that the success of RMCs depends crucially on the balance of control in their governance structures; GPwSIs influence demand only after close negotiations on an agreed and intermediate case mix; significant efficiencies are created by direct GP access to tests mainly when there is low diagnostic yield and high ‘rule-out’ rates; and referral guidelines are more likely to work when implemented by staff with responsibility for their creation. Conclusions The report concludes that there is no ‘preferred intervention’ that has the capacity to outperform all others. Instead, the review found many, diverse, hard-won, local and adaptive solutions. Whatever the starting point, success in demand management depends on synchronising a complex array of strategic, organisational, procedural and motivational changes. The final chapter offers practitioners some guidance on how they might ‘think through’ all of the interdependencies, which bring demand and capacity into equilibrium. A close analysis of the implementation of different configurations of demand management interventions in different local contexts using mixed methods would be valuable to understand the processes through which such interventions are tailored to local circumstances. There is also scope for further evidence synthesis. The substitution theory is ubiquitous in health and social care and a realist synthesis to compare the fortunes of different practitioners placed at different professional boundaries (e.g. nurses/doctors, dentists/dental care practitioners, radiologists/radiographers and so on) would be valuable to identify the contexts and mechanisms through which substitution, support or short-circuit occurs. Funding The National Institute for Health Research Health Services and Delivery Research programme.

/pdf/demand-management-for-planned-care-a-realist-synthesis-4ofj2q2awz.pdf

Demand management for planned care: a realist synthesis

Governing healthcare: Finding meaning in a clinical practice guideline for the management of non-specific low back pain

A comparative study of the construction and implementation of patient choice policies in the UK. Final report project 08/1718/147. Southampton: NIHR Service Delivery and Organisation programme,

Peckham, S; Sanderson, M; Entwistle, V; Thompson, A; Hughes, D; Prior, L; Allen, P; Mays, N; Brown, M; Kelly, G; +5 more... Powell, A; Baldie, D; Linyard, A; Duguid, A; Davies, H; (2011) A comparative study of the construction and implementation of patient choice policies in the UK. Final report project 08/1718/147. Southampton: NIHR Service Delivery and Organisation programme,. Technical Report. NHS National Institute of Health Research. http://researchonline.lshtm.ac.uk/id/eprint/19201 Downloaded from: http://researchonline.lshtm.ac.uk/19201/

A comparative study of the construction and implementation of patient choice policies in the UK.

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A comparative study of the construction and implementation of patient choice policies in the UK. Final report project 08/1718/147. Southampton: NIHR Service Delivery and Organisation programme,

A comparative study of the construction and implementation of patient choice policies in the UK.