Lessons from Europe: governance of health care providers

Successive UK and European governments have believed that granting a hospital the ability to make its own strategic or financial decisions will secure the quality, innovation and productivity required to improve health care delivery

Complementary logics of target-setting : hierarchist and experimentalist governance in the Scottish National Health Service

Where policy ends are contested and means for change are ambiguous, imposing central targets on local organisations – what we call hierarchist governance – is problematic. The concept of experimentalist governance suggests that target-setting should rather be a learning process between central regulators and local organisations. However, the relationship between experimentalist and hierarchist governance remains unclear. Existing literature suggests that the learning-oriented experimentalist logic is hard to reconcile with a hierarchist logic focussed on accountability for results. We examine whether complementary use of hierarchist and experimentalist ideas is possible. Drawing on experiences from Scotland, we find that experimentalist and hierarchist logics can co-exist in the same performance management system. Each logic served distinct roles with respect to target-setting, implementation and accountability. The emphasis on experimentalism was stronger where ends and means were contested (the case of shifting the balance of care for older people) than where both ends and means seemed obvious initially (the case of healthcare-associated infections, where target-setting followed a more hierarchist logic). However, governance drifted towards experimentalism when rising rates of community-acquired infections decreased clarity about effective interventions. The nature of policy issues and changes therein over time appear to be important conditions for synergies between governance logics

Efficiency measurement for management

The previous chapter has discussed the use of efficiency analysis tools to guide policy development and formulation. While few readers will doubt that clear, consistent policy direction is necessary for the delivery of productivity improvements, it is not sufficient. To lead to action on the ground, policy interventions have to influence the behaviour of the staff who see and treat patients, and deliver public health and social care programmes. In this chapter, we discuss the challenges facing management as it seeks to use the analytic tools discussed elsewhere in this volume to secure efficiency improvements

The Scottish NHS : meeting the financial challenge ahead

The Scottish NHS faces a crisis of affordability in the next couple of decades as the population ages and demands on services intensify. This presents two challenges: the first is how to redesign services to achieve greater efficiencies, and the second is how to engage the public so that there is a realistic public view about what is affordable, against which a mature discussion about the hard choices about funding and provision can take place. We refer to these as the innovation and openness challenges. In the paper we outline the current state of the system and discuss possible policy options. We conclude with some recommendations for next steps

Using information on variations to improve health system performance: from measurement to management

Although information on variations in healthcare utilisation is increasingly available, its constructive use to improve health systems is often hindered by the lack of a clear standard to evaluate what is “good“ and “poor“ performance. This thesis investigates how regulators and managers of the system might address this lack of a standard. The thesis distinguishes between the purpose (to manage ambiguity in the absence of a standard or to determine a meaningful standard) and the approach used to achieve either purpose (socio-political or technical-evidential). The resulting four types of strategies are examined by drawing on concepts and methods from public health and epidemiology, health economics, operations research and public administration and empirical evidence from England and Scotland. To manage ambiguity in the absence of a standard using a socio-political approach, the thesis finds that one must overcome a series of barriers including awareness, acceptance, perceived applicability and capacity of potential users. Clinical and managerial leadership appear to be enabling factors for the use of information on variations for strategic problem framing and stakeholder engagement. To manage ambiguity in the absence of a standard using a technical-evidential approach, the use of ranking intervals and dominance relations obtained from ratio-based efficiency analysis can help to avoid the forced assignment of a single, potentially controversial ranking to each organisation under scrutiny. To determine a standard using a technical-evidential approach, estimating capacity to benefit in populations provides a theoretically sound and feasible benchmark to assess the appropriateness of service utilisation against population needs. However, uncertainty about criteria of capacity to benefit and lack of epidemiological data remain practical challenges. To determine a standard using a socio-political approach, an experimentalist governance logic focused on learning and dialogue between central government and local organisations can complement a hierarchist logic focused on accountability when both the ideal ends and the means for attainment are ambiguous. As a whole, the thesis reinforces the insight that both improved technical tools and social and political processes are required to make information on variations useful to decision-maker

Developing robust composite measures of healthcare quality – ranking intervals and dominance relations for Scottish Health Boards

Although composite indicators are widely used to inform health system performance comparisons, such measures typically embed contentious assumptions, for instance about the weights assigned to constituent indicators. Moreover, although many comparative measures are constructed as ratios, the choice of denominator is not always straightforward. The conventional approach is to determine a single set of weights and to choose a single denominator, even though this involves considerable methodological difficulties. This study proposes an alternative approach to handle incomplete information about an appropriate set of weights and about a defensible denominator in composite indicators which considers all feasible weights and can incorporate multiple denominators. We illustrate this approach for comparative quality assessments of Scottish Health Boards. The results (displayed as ranking intervals and dominance relations) help identify Boards which cannot be ranked, say, worse than 4th or better than 7th. Such rankings give policy-makers a sense of the uncertainty around ranks, indicating the extent to which action is warranted. By identifying the full range of rankings that the organizations under comparison may attain, the approach proposed here acknowledges imperfect information about the “correct” set of weights and the appropriate denominator and may thus help to increase transparency of and confidence in health system performance comparisons

Lessons from Europe: assuring quality through regulation

The systems designed to assure the quality of care in England are under intense scrutiny following serious failures of care at Mid Staffordshire NHS Foundation Trust between 2005 and 2008. With the Francis report proposing far-reaching changes to how quality in the NHS is assured and regulated, a new briefing outlines key insights from the final Lessons from Europe seminar. The Lessons from Europe seminar series is organised jointly by LSE Health, the NHS European Office and the Health Services Research Network with funding from the ESRC