Payment by results and demand management: learning from the South Yorkshire laboratory

The need for effective demand management has become more transparent following the introduction of Payment by Results, Patient Choice and other reforms. This report details the findings of an empirical study exploring the South Yorkshire experience of demand management. By being ahead of the game in introducing PbR for all activity in all its acute trusts in the South Yorkshire area, the experience in South Yorkshire has the potential to inform the national roll-out of Payment by Results and Choose and Book. Specific objectives included: • assessing local perceptions of the nature and scale of changes in demand and whether this will be affected as other reforms, specifically Patient Choice, are implemented; • identifying what strategies are being developed locally to manage demand effectively; • documenting any benefits and drawbacks of different strategies for patients, PCTs, providers and the wider health economy; • identifying any facilitators and barriers to developing effective approaches for managing demand; • eliciting opinions on how current demand management strategies could be improved or adapted

Enabling Compassionate Health Care: Perils, Prospects and Perspectives

There is an emerging consensus that caring and compassion are under threat in the frenetic environment of modern healthcare. Enabling and sustaining compassionate care requires not only a focus on the needs of the patient, but also on those of the care giver. As such, threats and exhortations to health professionals are likely to have limited and perverse effects and it is to the organisational and system arrangements which support staff that attention should shift. Any approach to supporting compassionate care may work for some services, for some patients and staff, some of the time. No single approach is likely to be a panacea. Unravelling the contexts within which different approaches are effectual will allow for more selective development of support systems and interventions

The NHS performance framework: taking account of economic behaviour

The provision of quantitative information has been given a key role in securing good performance in the new NHS. A new National Performance Framework has been proposed encompassing a number of dimensions of performance. Whilst this approach to managing the NHS is welcomed, it is essential to understand the strengths and limitations intrinsic to the use of performance indicators for this purpose. In particular, complex behavioural consequences may arise in response to the collection and dissemination of performance data, some of which may be unintended, potentially dysfunctional and damaging for the NHS. Results from a recent study on the performance of NHS Trusts are used to illustrate the sort of unintended side-effects which occur within the current system and which may in principle be replicated in the new system in future. Whilst the possibility of such consequences does not invalidate the potential of the new Performance Framework to secure the desired changes in the NHS, it does suggest that careful attention needs to be paid to the assessment of unanticipated side-effects.performance, NHS Trusts

Contracting in the UK NHS: purpose, process and policy

Contracting has played a central role in the NHS reforms as the principal mechanism by which resources are transferred from purchasers to providers. The nature, process and role of contracting are traced by examining the development of government policy on this issue since the inception of the reforms. Much of the emphasis in the early years of the reforms was on getting the detail of contracting ‘right’, with attention becoming focused more recently on wider commissioning issues and the nature of the purchaser-provider relationship. The contracting environment is described and consideration is given to the way in which changes in this environment have influenced the role and nature of contracting, particularly in terms of the tension between the role of the market and the role of management in the NHS. Contracts have been used partly as a management tool and partly as a means to promote competition, often through the threat of competition (‘contestability’) rather than actually switching contracts between providers. The present government’s stated intention to abolish the internal market will lessen the role of contracts as a mechanism to promote competition, but within a “system of contestability to force improvements in standards” (Labour Party 1996). If contestability is to be used more radically in the NHS, a clearer separation may be required between the ownership and operation of assets to address issues of poor provider performance. Longer-term contracts (or agreements) then become the framework within which providers operate to meet purchaser service specifications, with an increasing emphasis on quality and effectiveness of services, and a decreasing emphasis on annual activity and price negotiations. The key challenge will lie in creating an appropriate set of incentives to reward efficient providers, and to ensure sufficient flexibility in longer-term agreements to challenge poor performance.NHS contracts

Clinical governance: striking a balance between checking and trusting

Clinical governance emerged as one of the big ideas central to the latest round of health reforms. It places with health care managers, for the first time, a statutory duty for quality of care on an equal footing with the pre-existing duty of financial responsibility (Warden 1998). Clinical governance tries to encourage an appropriate emphasis on the quality of clinical services by locating the responsibility for that quality along defined lines of accountability. This paper explores some of the implications of clinical governance using the economic perspective of principal-agent theory. It examines the ways in which principals seek to overcome the potential for agent opportunism either by reducing asymmetries of information (for example, by using performance data) or by aligning objective functions (for example, by creation of a shared quality culture). As trust and mutuality (or their absence) underpin all principal-agent relationships these issues lie at the heart of the discussion. The analysis emphasises the need for a balance between techniques that seek to compel performance improvements (through externally applied measurement and management), and approaches that trust to intrinsic professional motivation to deliver high quality services. Of crucial importance in achieving this balance is the creation and maintenance of the right organisational culture.governance

The Rise of Post-truth Populism in Pluralist Liberal Democracies: Challenges for Health Policy

Recent years have witnessed the rise of populism and populist leaders, movements and policies in many pluralist liberal democracies, with Brexit and the election of Trump the two most recent high profile examples of this backlash against established political elites and the institutions that support them. This new populism is underpinned by a post-truth politics which is using social media as a mouthpiece for ‘fake news’ and ‘alternative facts’ with the intention of inciting fear and hatred of ‘the other’ and thereby helping to justify discriminatory health policies for marginalised groups. In this article, we explore what is meant by populism and highlight some of the challenges for health and health policy posed by the new wave of post-truth populism

On Folk Devils, Moral Panics and New Wave Public Health

New wave public health places an emphasis on exhorting individuals to engage in healthy behaviour with good health being a signifier of virtuous moral standing, whereas poor health is often associated with personal moral failings. In effect, the medical is increasingly being collapsed into the moral. This approach is consistent with other aspects of contemporary neoliberal governance, but it fuels moral panics and creates folk devils. We explore the implications and dysfunctional consequences of this new wave of public health policy in the context of the latest moral panic around obesity