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Harris R, Perkins E, Holt R, Brown S, Garner J, Mosedale S, Moss P, Farrier A. Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIndependent contractor status of NHS general dental practitioners (GDPs) and general medical practitioners (GMPs) has meant that both groups have commercial as well as professional identities. Their relationship with the state is governed by a NHS contract, the terms of which have been the focus of much negotiation and struggle in recent years. Previous study of dental contracting has taken a classical economics perspective, viewing practitioners’ behaviour as a fully rational search for contract loopholes. We apply institutional theory to this context for the first time, where individuals’ behaviour is understood as being influenced by wider institutional forces such as growing consumer demands, commercial pressures and challenges to medical professionalism. Practitioners hold values and beliefs, and carry out routines and practices which are consistent with the field’s institutional logics. By identifying institutional logics in the dental practice organisational field, we expose where tensions exist, helping to explain why contracting appears as a continual cycle of reform and resistance.AimsTo identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services, using a comparison with medical practice to highlight factors which are particular to NHS dental practice.MethodsFollowing a systematic review of health-care contracting theory and interviews with stakeholders, we undertook case studies of 16 dental and six medical practices. Case study data collection involved interviews, observation and documentary evidence; 120 interviews were undertaken in all. We tested and refined our findings using a questionnaire to GDPs and further interviews with commissioners.ResultsWe found that, for all three sets of actors (GDPs, GMPs, commissioners), multiple logics exist. These were interacting and sometimes in competition. We found an emergent logic of population health managerialism in dental practice, which is less compatible than the other dental practice logics of ownership responsibility, professional clinical values and entrepreneurialism. This was in contrast to medical practice, where we found a more ready acceptance of external accountability and notions of the delivery of ‘cost-effective’ care. Our quantitative work enabled us to refine and test our conceptualisations of dental practice logics. We identified that population health managerialism comprised both a logic of managerialism and a public goods logic, and that practitioners might be resistant to one and not the other. We also linked individual practitioners’ behaviour to wider institutional forces by showing that logics were predictive of responses to NHS dental contracts at the dental chair-side (the micro level), as well as predictive of approaches to wider contractual relationships with commissioners (the macro level).ConclusionsResponses to contracts can be shaped by environmental forces and not just determined at the level of the individual. In NHS medical practice, goals are more closely aligned with commissioning goals than in general dental practice. The optimal contractual agreement between GDPs and commissioners, therefore, will be one which aims at the ‘satisfactory’ rather than the ‘ideal’; and a ‘successful’ NHS dental contract is likely to be one where neither party promotes its self-interest above the other. Future work on opportunism in health care should widen its focus beyond the self-interest of providers and look at the contribution of contextual factors such as the relationship between the government and professional bodies, the role of the media, and providers’ social and professional networks.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rebecca Harris
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Elizabeth Perkins
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Robin Holt
- Department of Organisation and Management, Management School, University of Liverpool, Liverpool, UK
| | - Steve Brown
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jayne Garner
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Sarah Mosedale
- Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Phil Moss
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Alan Farrier
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
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Bowler I, Gooding S. Health promotion in primary health care: the situation in England. PATIENT EDUCATION AND COUNSELING 1995; 25:293-299. [PMID: 7630833 DOI: 10.1016/0738-3991(95)00803-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
National policy, including changes to the management of the National Health Service, is intended to increase the amount of primary and secondary prevention in primary health care in England. The growth of financial power of general practitioners makes them key decision-makers in planning and delivering health promotion. The vast majority of people in contact with their family doctor could benefit from making appropriate lifestyle modifications. However, the level and quality of health promotion activity in primary care is variable, with many patients not receiving interventions. A review of research indicates that both skepticism about the relationship between behaviour and risk factor, and lack of confidence in efficacy of health promotion in changing patient behaviour act as barriers to general practitioners taking on more health promotion activity. For prevention work to increase, therefore, general practitioners require more evidence of effective replicable interventions, and appropriate training on the design and implementation of programmes. The role of the Health Education Authority, the national agency for health promotion in England, in meeting these needs is described. The paper also includes a brief discussion of evaluation methods for assessing the success of health promotion interventions.
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Affiliation(s)
- I Bowler
- Wandsworth Borough Council, London, UK
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Abstract
The focus of this paper is the extent to which the purchaser-provider split and the creation of a market in the provision of health care can be expected to bring about greater efficiency within the new NHS. The starting point is a theoretical discussion of markets and competition. In particular, emphasis is placed upon the economic model of perfect competition. It is argued that because of the existence of externalities, uncertainty and a lack of perfect information, an unregulated market in health care will almost certainly fail. In view of this, the imperfect provider markets of monopoly and contestable markets, which are of particular relevance to health care, are discussed. A description of the new health care market and the principal actors within it is followed by an evaluation of the new health care market. It is argued that in view of the restrictions to competition that exist between providers, some form of price regulation will be necessary to prevent monopolistic behaviour in the hospital sector. Regulation of purchasers is also suggested as a means of improving efficiency. It is concluded that competition may be a necessary condition for increased efficiency in health care provision, but is not sufficient in itself. Other incentives in the hospital sector are necessary to assist the market process and to enhance its impact on efficiency.
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Affiliation(s)
- P Shackley
- Department of Public Health, University of Aberdeen, UK
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Hughes D. General practitioners and the new contract: promoting better health through financial incentives. Health Policy 1993; 25:39-50. [PMID: 10129158 DOI: 10.1016/0168-8510(93)90101-t] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this paper the changes in payment of general practitioners in the UK, introduced in the 1990 contract, are described in detail. The effects of the changes on the structure of general practitioners' incomes is discussed. More emphasis on capitation payments may increase preventive activity in general practice, but, depending on the level at which the capitation fee is set, could lead to shifting of patients to other sectors in the health care economy. Target payments appear to have been successful in increasing the numbers of smears taken. It is clear that doctors respond to financial incentives, but what is not clear is whether their responses will always be in the way intended or lead to more efficient practice.
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Affiliation(s)
- D Hughes
- Department of Public Health, University of Aberdeen, UK
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