Does hospital ownership affect patient experience? An investigation into public-private sector differences in England

The impact of NHS outsourcing of elective care to the independent sector on outcomes for patients, healthcare professionals and the United Kingdom health care system: A rapid narrative review of literature

The NHS is increasingly turning to the independent sector, primarily to alleviate elective care backlogs. However, implications for the healthcare system, patients and staff are not well understood. This paper provides a rapid narrative review of research evidence on NHS-funded elective care in the independent sector (IS) and the impact on patients, professionals, and the health care system. The aim was to identify the volume and evaluate the quality of the literature whilst providing a narrative synthesis. Studies were identified through Medline, CINAHL, Econlit, PubMed, Web of Science and Scopus. The quality of the included studies was assessed in relation to study design, sample size, relevance, methodology and methodological strength, outcomes and outcome reporting, and risk of bias. Our review included 40 studies of mixed quality. Many studies used quantitative data to analyse outcome trends across and between sectors. Independent sector providers (ISPs) can provide high-volume and low-complexity elective care of equivalent quality to the NHS, whilst reducing waiting times in certain contexts. However it is clear that the provision of NHS-funded elective care in the IS has a range of implications for public provision. These surround access and outcome inequalities, financial sustainability and NHS workforce impacts. It will subsequently be important for future empirical work to incorporate these caveats, providing a more nuanced interpretation of quantitative improvements.

Factors influencing patient experience in hospital wards: a systematic review

BACKGROUND

Patient experience plays an essential role in improving clinical effectiveness and patient safety. It's important to identify factors influencing patient experience and to improve quality of healthcare.

OBJECTIVE

To identify factors that influence patient experience in hospital wards.

METHODS

We conducted a systematic review including six databases; they were PubMed, CINAHL, Embase, PsycInfo, ProQuest, and Cochrane. Studies were included if they met the inclusion criteria. The JBI checklist was used to perform quality appraisal. We used 5 domains of the ecological model to organize and synthesize our findings to comprehensively understand the multi-level factors influencing the issue.

RESULT

A total of 138 studies were included, and 164 factors were identified. These factors were integrated into 6 domains. All domains but one (survey-related factors) could be mapped onto the attributes of the ecological framework: intrapersonal, interpersonal, institutional, community, and public policy level factors. All factors had mixed effect on patient experience. The intrapersonal level refers to individual characteristics of patients. The interpersonal level refers to interactions between patients and healthcare providers, such as the caring time spent by a nurse. The institutional level refers to organizational characteristics, rules and regulations for operations, such as hospital size and accreditation. The community level refers to relationships among organizations, institutions, and informational networks within defined boundaries, such as a hospital located in a larger population area. Public policy level refers to local, state, national, and global laws and policies, including health insurance policies. The sixth domain, survey-related factors, was added to the framework and included factors such as survey response rate and survey response time.

CONCLUSION

The factors influencing patient experience are comprehensive, ranging from intrapersonal to public policy. Providers should adopt a holistic and integrated perspective to assess patient experience and develop context-specific interventions to improve the quality of care. PROSPERO REGISTRATION NUMBER CRD42023401066.

'Accident and emergency'? Exploring the reasons for increased privatisation in England's NHS

England's NHS is experiencing rising privatisation as services are increasingly being delivered by private healthcare providers. This has led to concerns about the supposed benefit of this process on healthcare quality but the reasons for the increase - and whether processes prioritise quality - are not well understood. In-depth semi-structured interviews with 20 people involved in the commissioning process, sampled from 3 commissioning sites (regional health boards) are thematically analysed. Four key themes of reasons for outsourcing were identified: unmet need; the "choice agenda"; appetite for change amongst key individuals working at the commissioning body; and the impact of financial pressures. The study concludes that the experience of commissioners navigating the provision of healthcare with worsening social determinants of health and financial austerity means that decisions to use private providers based on anticipated quality are sometimes but not always possible - sometimes they constitute 'accidents', sometimes 'emergencies'.

The sorting effect in healthcare access: Those left behind

Many governments have sought to enhance patient choice in hospital by intensifying competitive pressure on hospital administrations that is expected to improve efficiency, quality, and innovation. However, there is mixed evidence on whether patients travel past their local hospitals to seek better quality care and whether higher-income patients are those most sensitive to respond to competitive pressures. Using detailed data from 17 million inpatient stays admitted in France during 2019, this paper explores patients' choice of provider where for-profit, non-profit, research hospital and local hospitals are allowed to compete with each other. We estimate the extent to which deprivation gradient plays on patient's choice of provider. We found that, in general, patients travel for their care, with just one-quarter of them going to the nearest hospital. In fact, the most vulnerable patients (i.e., those socio-economically deprived, and very aged) are mostly treated in local public hospitals with the lowest quality service level, and with large variability in quality as well, while those with less socio-economic deprivation seek care at higher-quality for-profit hospitals. Our counterfactual simulations show that admission to university hospitals attenuates existing inequalities. However, whether it delays the healthcare access sought by this population remains an open question.

Patient satisfaction with nursing care in Iran: a systematic review and meta-analysis

Introduction

Patient satisfaction (PS) with nursing care is considered one of the most important predictors of satisfaction with hospital services. The current research was conducted to determine the level of PS with nursing care provided in hospitals in Iran.

Methods

A comprehensive systematic search was conducted in various international electronic databases, such as PubMed, Scopus, Web of Science, and Persian electronic databases such as Iranmedex, and the Scientific Information Database (SID) using keywords extracted from Medical Subject Headings such as 'Patient satisfaction', 'Satisfaction', 'Nursing care', and 'Nurse' from the earliest to 27 January 2023. The risk of bias was assessed using the Joanna Briggs Institute (JBI) scale, and the analysis was performed in Stata software version 14. Subgroup and sensitivity analyses were performed to clarify the source of heterogeneity.

Results

The results showed that the overall PS with nursing care in different hospitals was 0.83 (95% CI: 0.79-0.86). The proportions of complete satisfaction, partial satisfaction, and dissatisfaction were 0.38 (95% CI: 0.23-0.53), 0.45 (95% CI: 0.34-0.55), and 0.17 (95% CI: 0.12-0.21), respectively.

Conclusion

However, overall satisfaction was seen in four out of five patients admitted to hospitals in Iran, complete satisfaction with nursing care was 38%. Future studies should identify the effective factors related to PS with nursing care.

Public and Private Options in Practice: The Military Health System

Recent debates over health care reform, including in the context of the Military Health System (MHS) and Veterans Administration, highlight the dispute between public and private provision of health care services. Using novel data on childbirth claims from the MHS and drawing on the combination of plausibly exogenous patient moves and heterogeneity across bases in the availability of base hospitals, we identify the impact of receiving obstetrical care on versus off military bases. We find evidence that off-base care is associated with slightly greater resource intensity, but also notably better outcomes, suggesting marginal efficiency gains from care privatization.

A paradigm shift for medical health care to focus on a service-value approach to achieve greater patient satisfaction

PURPOSE

This study takes a divergent approach to exploring which construct is more predictive of patient satisfaction (SAT) in a service dominant economy within the context of a healthcare setting.

DESIGN/METHODOLOGY/APPROACH

Applying a critical analysis of literature, a service value (SV) model for customer SAT is proposed in this study, which is validated and confirmed with survey data from outpatients at Moorfields Eye Hospital - a world class specialist hospital based in the UK.

FINDINGS

Quality of service had the strongest impact on SV but SV had the strongest impact and mediation effect on patient SAT.

RESEARCH LIMITATIONS/IMPLICATIONS

The study concludes that since SV rather than quality of service is more predictive of patient SAT, health service providers should focus more on SV in addition to quality of service, if they are to meet the dynamic expectations of their patients.

PRACTICAL IMPLICATIONS

Health service providers should focus more on SV in addition to quality of service, if they are to meet the dynamic expectations of their patients.

SOCIAL IMPLICATIONS

This poses a strong argument in favour of a paradigm shift in focus from quality of service-based model to service value-based model for greater patient satisfaction.

ORIGINALITY/VALUE

This is the first study exploring the inter-relationship of four constructs of patient SAT within the context of a leading major UK healthcare hospital service.

Organizational arrangements as a key to enhancing innovativeness and efficiency - analysis of a restructuring hospital in Finland

Background

Challenged to innovate and improve efficiency both at the policy level and in everyday work, many health care organizations are undergoing radical change. However, in many earlier studies, the significance of individuals’ perceptions of their organization and its innovativeness and efficiency during restructuring is not well acknowledged. Our study examines how various organizational arrangements; performance-, hierarchy-, tradition-, and leader-focused types, as well as collaborative and fragmented ones, connect to reaching innovativeness and efficiency in health care during restructuring.

Method

We built on previous organization and management research, innovation studies, and on research focusing in health care restructuring, and conducted an exploratory quantitative case study in a public sector hospital in Finland. Data comprising 447 responses from 19 professional groups across the hospital was analyzed using hierarchical regression analysis.

Results

Our results demonstrate that multiple, co-existing organizational arrangements can promote innovation and efficiency. The perceptions of the organizational members of the nature of their organization need to be generally positive and reflect future-orientation to show positive connections with efficiency and innovativeness; fragmentation in the members’ perceptions of the character of their organization and their inability to go beyond established organizational traditions pose risks of inefficiency and stagnation rather than fruitful exploration. Our study further shows, somewhat surprisingly, that while collaborative organizational arrangements are positively related to increases in perceived efficiency, the same does not apply to innovativeness.

Conclusions

Our study addresses understudied, yet inherently important aspects in providing high-quality health care: the relationships between different organizational arrangements and exploitation and exploration-related outcomes. In particular, examination of individuals’ perceptions (that may have even more weight for the subsequent developments than the actual situation) adds insight to the existing knowledge that has addressed more objective factors. Implications on how to support high levels of performance are drawn for management of professional and pluralistic organizations undergoing restructuring. Our findings also generate information that is useful for policy making concerned with public sector health care.

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation

BACKGROUND

The effects of outsourcing health services to for-profit providers are contested, with some arguing that introducing such providers will improve performance through additional competition while others worry that this will lead to cost cutting and poorer outcomes for patients. We aimed to examine this debate by empirically evaluating the impact of outsourced spending to private providers, following the 2012 Health and Social Care Act, on treatable mortality rates and the quality of health-care services in England.

METHODS

For this observational study, we used a novel database composed of parsable procurement contracts between April 1, 2013, and Feb 29, 2020 (n=645 674, value >£25 000, total value £204·1 billion), across 173 clinical commissioning groups (CCGs; regional health boards) in England. Data were compiled from 12 709 heterogenous expenditure files primarily scraped from commissioner websites with supplier names matched to registers identifying them as National Health Service (NHS) organisations, for-profit companies, or charities. We supplemented these data with rates of local mortality from causes that should be treatable by medical intervention, indicating the quality of health-care services. We used multivariate longitudinal regression models with fixed effects at the CCG level to analyse the association of for-profit outsourcing on treatable mortality rates in the following year. We used the average marginal effects to estimate total additional deaths attributable to changes in for-profit outsourcing. We provided alternative model specifications to test the robustness of our findings, match on background characteristics, examine the potential impact of measurement error, and adjust for possible confounding factors such as population demographics, total CCG expenditure, and local authority expenditure.

FINDINGS

We found that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable mortality of 0·38% (95% CI 0·22-0·55; p=0·0016) or 0·29 (95% CI 0·09-0·49; p=0·0041) deaths per 100 000 population in the following year. This finding was robust to matching on background characteristics, adjusting for possible confounding factors, and measurement error in our dataset. Changes to for-profit outsourcing since 2014 were associated with an additional 557 (95% CI 153-961) treatable deaths across the 173 CCGs.

INTERPRETATION

The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased in 2013-20. Private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services.

FUNDING

Wellcome Trust.

Divided by choice? For-profit providers, patient choice and mechanisms of patient sorting in the English National Health Service

This paper studies patient choice of provider following government reforms in the 2000s, which allowed for-profit surgical centers to compete with existing public National Health Service (NHS) hospitals in England. For-profit providers offer significant benefits, notably shorter waiting times. We estimate the extent to which different types of patients benefit from the reforms, and we investigate mechanisms that cause differential benefits. Our counterfactual simulations show that, in terms of the value of access, entry of for-profit providers benefitted the richest patients twice as much as the poorest, and white patients six times as much as ethnic minority patients. Half of these differences is explained by healthcare geography and patient health, while primary care referral practice plays a lesser, though non-negligible role. We also show that, with capitated reimbursement, different compositions of patient risks between for-profit surgical centers and existing public hospitals put public hospitals at a competitive disadvantage.

The Association of Market Mix of Hospital Ownership With Medical Disputes: Evidence From China

The prevalence and severity of medical disputes in China have attracted the attention of society and academia, and how to alleviate medical disputes has become a major concern. Following the implementation of a series of policies, the private sector in China’s hospital market has expanded rapidly over the past decade. It remains unknown whether the market mix of hospital ownership could alleviate medical disputes, this study aims to bridge the gap. Data are collected from all hospitals (2171) in Sichuan province, China, from 2012 to 2015. Using a negative binomial hurdle model, the results show that for hospitals with disputes, the private hospital market share has an inverted U-shaped relationship with the number of disputes. However, no significant relationship is found between the private hospital market share and the probability of dispute occurrence. For hospitals with disputes, competition plays a protective role in the effect of the private hospital market share on the number of disputes, hindering the increase in the number of disputes and facilitating a more rapid drop. However, medical quality is found to play an insignificant role in that effect. The findings also support encouraging new private hospitals in China rather than privatizing existing public hospitals.

Is it worth outsourcing essential public health services in China?-Evidence from Beilin District of Xi'an

BACKGROUND

Essential public health services (EPHS) is general welfare public health interventions led by the Chinese government and provided by the primary medical institutions to all residents. In Beilin District, Xi'an, EPHS producers can be divided into outsourced institutions and public institutions.

OBJECTIVE

Can outsourcing EPHS reduce costs and improve efficiency and quality? There is still no definite answer to this question. This paper compares the performance of outsourced institutions and public institutions in terms of efficiency and quality, explains the reasons for this phenomenon.

METHODS

This paper uses a theoretical and two-stage DEA model Based on a "triple subject" research framework.

RESULTS

The results show that the difference between public institutions and outsourced institutions is mainly reflected in service quality. When the quality is not measured, outsourced institutions' production efficiency is higher than that of public institutions. When there are quality measurements, the production efficiency of outsourced institutions is lower than that of public institutions.

CONCLUSIONS

Outsourced institutions perform worse than public institutions. The reason is that a bilateral monopolistic market structure has formed between local governments and outsourced institutions. This situation makes it difficult for the government to replace poor quality outsourced institutions under the constraints of a limited budget.

Examining the variation across acute trusts in patient delayed discharge

Delayed transfers of care, or delayed discharges, adversely affect patient care and increase costs to England's National Health Service. The main objective of this paper is to explain variation in the probability of delayed discharge from an acute trust and patient perspective. A novel approach is employed in using the Adult Inpatient Survey over the period 2007-2014. We use a two stage regression model to assess the impact of various patient, acute hospital trust, and regional characteristics on the probability of delayed discharge. In the first stage we model the patient-level probability of delayed discharge and estimate hospital trust-specific fixed-effects. Stage two includes multiple linear regressions to explain acute trust fixed effects from stage one by using acute trust characteristics and regional observable characteristics as explanatory variables. Results indicate the probability of delayed discharge varies among acute trusts and patients. Patient-mix complexity, staff skill-mix, size and scope of acute trust are among those factors affecting the trust-specific discharge efficiency.

Does Ownership Matter for Medical System Performance? Evidence From a Natural Experiment in Suqian, China

There has long been a major policy debate on the role of hospital ownership (private vs public) in medical system performance. China’s health care delivery system is mainly a public system. In 2000, a full privatization reform was implemented in the city of Suqian, offering a unique opportunity to assess possible effects of private delivery based on a major external shock to the existing system. Compared with all other cities in Jiangsu province since 2003, Suqian did not experience any greater increase either in total outpatient or inpatient expenditures. In the meantime, Suqian performed equally well as other cities in terms of changes in number of inpatient admissions and average inpatient days, and even better for mortality rate in emergency rooms. This study concludes that under appropriate public financing, private delivery can serve the public demand at least equally well as public providers in terms of cost inflations and utilizations.

Do independent treatment centers offer more value than general hospitals? The case of cataract care

OBJECTIVE

To identify differences between independent treatment centers (ITCs) and general hospitals (GHs) regarding costs, quality of care, and efficiency.

DATA SOURCES

Anonymous claims data (2013-2015) were used. We also obtained quality indicators from a semipublic platform.

STUDY DESIGN

This study uses a comparative multilevel analysis, controlling for case mix, to evaluate the performance of ITCs and GHs for patients diagnosed with cataract.

DATA COLLECTION

Reimbursement claims were extracted from existing claims databases of the largest Dutch health insurer. Quality indicators were obtained by external agencies through a mixed-mode survey.

PRINCIPAL FINDINGS

There are no stark differences in complexity of cases for cataract care. ITCs seem to perform surgeries more frequently per care pathway, but conduct a lower number of health care activities per surgical claim. Total average costs are lower in ITCs compared with GHs, but when adjusted for case mix, the differences in costs are lower. The findings with the adjusted quality differences suggest that ITCs outperform GHs on patient satisfaction, but patients' outcomes are similar.

CONCLUSION

This finding supports the postulation-based on the focus factory theory-that ITCs can provide more value for cataract care than GHs.

Payment systems and hospital length of stay: a bunching-based evidence

Despite the huge attention on the long average hospital length of stay (LOS) in Japan, there are limited empirical studies on the impacts of the payment systems on LOS. In order to shed new light on this issue, we focus on the fact that reimbursement for hospital care is linked to the number of patient bed-days, where a "day" is defined as the period from one midnight to the next. This "midnight-to-midnight" definition may incentivize health care providers to manipulate hospital acceptance times in emergency patients, as patients admitted before midnight would have an additional day for reimbursement when compared with those admitted after midnight. We test this hypothesis using administrative data of emergency transportations in Japan from 2008 to 2011 (N = 2,146,498). The results indicate that there is a significant bunching in the number of acceptances at the emergency hospital around midnight; the number heaps a few minutes before midnight, but suddenly drops just after midnight. Given that the occurrence of emergency episode is random and the density is smooth during nighttime, bunching in the number of hospital acceptances around midnight suggests that hospital care providers shift the hospital acceptance times forward by hurrying-up to accept the patients. This manipulation clearly leads to longer LOS by one bed-day. In addition, the manipulation is observed in the prefectures where private hospitals mainly provide emergency medical services, suggesting hospital ownership is associated with the manipulation of hospital acceptance time.

Hospital Choice for Cataract Treatments: The Winner Takes Most

Background: Transparency in quality of care is an increasingly important issue in healthcare. In many international healthcare systems, transparency in quality is crucial for health insurers when purchasing care on behalf of their consumers, for providers to improve the quality of care (if necessary), and for consumers to choose their provider in case treatment is needed. Conscious consumer choices incentivize healthcare providers to deliver better quality of care. This paper studies the impact of quality on patient volume and hospital choice, and more specifically whether high quality providers are able to attract more patients.

Methods: The dataset covers the period 2006-2011 and includes all patients who underwent a cataract treatment in the Netherlands. We first estimate the impact of quality on volume using a simple ordinary least squares (OLS), second we use a mixed logit to determine how patients make trade-offs between quality, distance and waiting time in provider choice.

Results: At the aggregate-level we find that, a one-point quality increase, on a scale of one to a hundred, raises patient volume for the average hospital by 2-4 percent. This effect is mainly driven by the hospital with the highest quality score: the effect halves after excluding this hospital from the dataset. Also at the individual-level, all else being equal, patients have a stronger preference for the hospital with the highest quality score, and appear indifferent between the remaining hospitals.

Conclusion: Our results suggest that the top performing hospital is able to attract significantly more patients than the remaining hospitals. We find some evidence that a small share of consumers may respond to quality differences, thereby contributing to incentives for providers to invest in quality and for insurers to take quality into account in the purchasing strategy.

Do private hospitals outperform public hospitals regarding efficiency, accessibility, and quality of care in the European Union? A literature review

European countries have enhanced the scope of private provision within their health care systems. Privatizing services have been suggested as a means to improve access, quality, and efficiency in health care. This raises questions about the relative performance of private hospitals compared with public hospitals. Most systematic reviews that scrutinize the performance of the private hospitals originate from the United States. A systematic overview for Europe is nonexisting. We fill this gap with a systematic realist review comparing the performance of public hospitals to private hospitals on efficiency, accessibility, and quality of care in the European Union. This review synthesizes evidence from Italy, Germany, the United Kingdom, France, Greece, Austria, Spain, and Portugal. Most evidence suggests that public hospitals are at least as efficient as or are more efficient than private hospitals. Accessibility to broader populations is often a matter of concern in private provision: Patients with higher social-economic backgrounds hold better access to private hospital provision, especially in private parallel systems such as the United Kingdom and Greece. The existing evidence on quality of care is often too diverse to make a conclusive statement. In conclusion, the growth in private hospital provision seems not related to improvements in performance in Europe. Our evidence further suggests that the private (for-profit) hospital sector seems to react more strongly to (financial) incentives than other provider types. In such cases, policymakers either should very carefully develop adequate incentive structures or be hesitant to accommodate the growth of the private hospital sector.

Comparing public and private providers: a scoping review of hospital services in Europe

BACKGROUND

What is common to many healthcare systems is a discussion about the optimal balance between public and private provision. This paper provides a scoping review of research comparing the performance of public and private hospitals in Europe. The purpose is to summarize and compare research findings and to generate questions for further studies.

METHODS

The review was based on a methodological approach inspired by the British EPPI-Centre's methodology. This review was broader than review methodologies used by Cochrane and Campbell and included a wider range of methodological designs. The literature search was performed using PubMed, EconLit and Web of Science databases. The search was limited to papers published from 2006 to 2016. The initial searches resulted in 480 studies. The final sample was 24 papers. Of those, 17 discussed economic effects, and seven studies addressed quality.

RESULTS

Our review of the 17 studies representing more than 5500 hospitals across Europe showed that public hospitals are most frequently reported as having the best economic performance compared to private not-for-profit (PNFP) and private for-profit (PFP) hospitals. PNFP hospitals are second, while PFP hospitals are least frequently reported as superior. However, a sizeable number of studies did not find significant differences. In terms of quality, the results are mixed, and it is not possible to draw clear conclusions about the superiority of an ownership type. A few studies analyzed patient selection. They indicated that public hospitals tend to treat patients who are slightly older and have lower socioeconomic status, riskier lifestyles and higher levels of co-morbidity and complications than patients treated in private hospitals.

CONCLUSIONS

The paper points to shortcomings in the available studies and argues that future studies are needed to investigate the relationship between contextual circumstances and performance. A big weakness in many studies addressing economic effects is the failure to control for quality and other operational dimensions, which may have influenced the results. This weakness should also be addressed in future comparative studies.

Socioeconomic inequality of access to healthcare: Does choice explain the gradient?

Equity of access is a key policy objective in publicly-funded healthcare systems. However, observed inequalities of access by socioeconomic status may result from differences in patients' choices. Using data on non-emergency coronary revascularisation procedures in the English National Health Service, we found substantive differences in waiting times within public hospitals between patients with different socioeconomic status: up to 35% difference, or 43 days, between the most and least deprived population quintile groups. Using selection models with differential distances as identification variables, we estimated that only up to 12% of these waiting time inequalities can be attributed to patients' choices of hospital and type of treatment (heart bypass versus stent). Residual inequality, after allowing for choice, was economically significant: patients in the least deprived quintile group benefited from shorter waiting times and the associated health benefits were worth up to £850 per person.

Evaluating the impact of continuous quality improvement methods at hospitals in Tanzania: a cluster-randomized trial

Objective

To evaluate the impact of implementing continuous quality improvement (CQI) methods on patient's experiences and satisfaction in Tanzania.

Design

Cluster-randomized trial, which randomly allocated district-level hospitals into treatment group and control group, was conducted.

Setting

Sixteen district-level hospitals in Kilimanjaro and Manyara regions of Tanzania.

Participants

Outpatient exit surveys targeting totally 3292 individuals, 1688 in the treatment and 1604 in the control group, from 3 time-points between September 2011 and September 2012.

Intervention

Implementation of the 5S (Sort, Set, Shine, Standardize, Sustain) approach as a CQI method at outpatient departments over 12 months.

Main outcome measures

Cleanliness, waiting time, patient's experience, patient's satisfaction.

Results

The 5S increased cleanliness in the outpatient department, patients' subjective waiting time and overall satisfaction. However, negligible effects were confirmed for patient's experiences on hospital staff behaviours.

Conclusions

The 5S as a CQI method is effective in enhancing hospital environment and service delivery; that are subjectively assessed by outpatients even during the short intervention period. Nevertheless, continuous efforts will be needed to connect CQI practices with the further improvement in the delivery of quality health care.

A qualitative study of diverse providers' behaviour in response to commissioners, patients and innovators in England: research protocol

INTRODUCTION

The variety of organisations providing National Health Service (NHS)-funded services in England is growing. Besides NHS hospitals and general practitioners (GPs), they include corporations, social enterprises, voluntary organisations and others. The degree to which these organisational types vary, however, in the ways they manage and provide services and in the outcomes for service quality, patient experience and innovation, remains unclear. This research will help those who commission NHS services select among the different types of organisation for different tasks.

RESEARCH QUESTIONS

The main research questions are how organisationally diverse NHS-funded service providers vary in their responsiveness to patient choice, NHS commissioning and policy changes; and their patterns of innovation. We aim to assess the implications for NHS commissioning and managerial practice which follow from these differences.

METHODS AND ANALYSIS

Systematic qualitative comparison across a purposive sample (c.12) of providers selected for maximum variety of organisational type, with qualitative studies of patient experience and choice (in the same sites). We focus is on NHS services heavily used by older people at high risk of hospital admission: community health services; out-of-hours primary care; and secondary care (planned orthopaedics or ophthalmology). The expected outputs will be evidence-based schemas showing how patterns of service development and delivery typically vary between different organisational types of provider.

ETHICS, BENEFITS AND DISSEMINATION

We will ensure informants' organisational and individual anonymity when dealing with high profile case studies and a competitive health economy. The frail elderly is a key demographic sector with significant policy and financial implications. For NHS commissioners, patients, doctors and other stakeholders, the main outcome will be better knowledge about the relative merits of different kinds of healthcare provider. Dissemination will make use of strategies suggested by patient and public involvement, as well as DH and service-specific outlets.

Communicative characteristics of interactions between surgeons and Chinese women with breast cancer in oncology consultation: a conversation analysis

BACKGROUND

While previous studies have analysed features of interaction in cancer consultations using observational coding frames, relatively little attention is being given to how actual interactions are sequentially organized and achieved by participants in the course of talk-in-interaction. Research into the interactional practices in consultations, which involves Chinese patients, is largely absent.

OBJECTIVE

To provide insight into the talk-in-interaction in surgical-oncology consultations in the context of a Chinese medical setting.

METHODS

Thirty-one consultations involving 31 patients with breast cancer and eight surgeons were videotaped. The recordings were transcribed verbatim and analysed using conversation analysis.

RESULTS

The manner in which surgeons delivered the diagnostic results was fairly similar across all the consultations. Most surgeons gave the diagnosis in a very straightforward and abrupt manner at the outset of the consultation with no mitigation. While patients in our study conformed to the traditional information giving and receiving roles, how information was presented by surgeons shaped the subsequent sequential organization of surgeon-patient interaction and turn-taking patterns. More importantly, there was a tendency by the surgeons to move from issues of psychosocial nature to clinical matters regardless of the topics taken up in the specific encounter.

CONCLUSIONS

This study demonstrated the potential of conversation analysis as a context-sensitive method that enabled researchers to gain a more thorough understanding of dynamics of interaction in cancer consultations, thereby informing training interventions for surgeons. Our findings underscore the importance of discursive practices in shaping and encouraging (or discouraging) patient participation in oncology consultation.