autonomy and local relationships in the english nhs mark exworthy - [email protected] francesca...
TRANSCRIPT
Autonomy and local relationships in the English NHS
Mark Exworthy - [email protected]
Francesca Frosini – [email protected]
Lorelei Jones - [email protected]
Research funded by NHS SDO R&D programmehttp://www.sdo.lshtm.ac.uk/sdo1252006.html
Paper presented to the European Health Management Association conference, Athens, 25-27 June 2008
Outline
Conceptual background
– Vertical and horizontal autonomy
– “Decision space” in local health economies
Empirical study from the English NHS
– Emerging findings
1
Central policies determine the “decision space” available locally
Central policies determine the set of incentives
Exercise of choice is “shaped” by and is “interdependent” with other local actors
Horizontal Autonomy
Conceptual BackgroundVertical and horizontal autonomy
Bossert T. (1998). ‘Analyzing the decentralisation of health systems in developing countries: decision space, innovation and performance’. Social Science and Medicine, 47, 10, pp.1513-1527
Exworthy M. and Frosini F. (2008).’Room for manoeuvre? Explaining local autonomy in the English National Health Service’. Health Policy, 86, pp204-212
2
Vertical Autonomy
Conceptual background: “Decision Space Framework”
Central Policies
Decision Space/Vertical Autonomy
Social and InstitutionalEmbeddedness
Local Choice
Innovation No Change
Performance Performance
3
Local Level
Outcomes
Government
Incentives Directed Change
Performance
The structure of the NHS
Vertical and Horizontal autonomy in the NHS: the Local Health Economy
13
Restructuring
Market-based reforms
Targets and terror
Public participation
Guidelines and recommendations
Non local PCTs
Foundation Trust
Local PCT
NHS Trusts
Non local PCTs
Local Gvt
Horizontal / Local RelationshipsVertical Autonomy
Clinical Networks
Financial Flows
The StudyMethodology
Comparative longitudinal case-study of 2 contrasting LHEs (2006-2009)
This presentation reports from phase 1 in one LHE
Data collection• Interviews with 23 clinicians and managers
• Observation at public and private meetings
• Documentary / secondary data analysis
13
Dilution of management energy and resources
Diversion of energy and resources to most pressing issues
Findings
2
•Multiple contradictory policies
•Rapid pace of change
Findings
In the context of policy turbulence and upheaval, organisational performance is associated with long-standing relationships that engender trust
Performance associated with long-standing relationships
[Forest Hospital] has also been very reluctant to give up the OG cancer which I talked about, so
there's lots of tensions between our organisations but the clinicians just kind of, just get on with it
really, you know just … so a few little chats in the room together and man- it's the management that
find it difficult
Cathy, General manager - surgery, County General
Loyalty of patients to local providersResistance by purchasers to threaten
viability of local providers
Market-based reformsRestructuringReconfigurationNew staff
Disruption of social and institutional relations
Findings
2
Persistence of social and institutional relations
Persistence of social and institutional relations
Loyalty of patients to local providers
We will offer a patient five places to go and appointment times at those five places- that's what it says, it doesn't mean it's going to be within your county, or within you district, it's anywhere within the country, so- so all she does is she logs out of the Choose & Book screen and writes me a letter and sends it in, so I mean, so that's all that's happening, there is no choice- patients don't want choice, patients want to be
treated in their local hospital
Bob, Clinical Director of orthopaedics, Forest Hospital
Disruption of social and institutional relations
New Staff
Well it's difficult because you- you just have to you know, new people come and you end up with a different set of
relationships, sometimes that's been helpful, sometimes it's been less helpful but you know, it has caused some
difficulties where you develop some strategic alliances and you know, new people come in and want to change those alliances for all sort of you know, reasons and you know,
that can disrupt continuity
Chris, CEO, Forest Hospital (FT)
Disruptions of social and institutional relations
Reconfiguration
...and I mean it- it brought out I think in that situation often brings out the worst in people and sours relationships
which then take a long time to recover so I think it's been very detrimental to the area and probably the reason why we're now thinking about joining with [the other hospital] as opposed to- some might say the more logical thing is for us to join with County hospital first and then go West, sorry
go East towards [the other hospital] is that the relationships between us and [County] hospital have been
soured by, I think, by the whole process, so it wasn't a particularly constructive or useful thing to go through.
Bob, Clinical Director of orthopaedics, Forest Hospital
Policy does not have intended consequences Referrals patterns are maintained Providers negotiate market share
Policy has unintended consequences Conflict between actors Lack of trust leading to inefficiencies
Local autonomy is highly contingent on relationships within local health economies and national policy
Disruption of social and institutional relations
Consequences
2
Persistence of social and institutional relations
Autonomy and collaboration