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Sheaff R, Ellis-Paine A, Exworthy M, Hardwick R, Smith CQ. Commodification and healthcare in the third sector in England: from gift to commodity-and back? PUBLIC MONEY & MANAGEMENT 2023; 44:298-307. [PMID: 38919878 PMCID: PMC11197995 DOI: 10.1080/09540962.2023.2244350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
IMPACT This article suggests why a different approach may be required for commissioning services from third sector providers than from, say, corporate or public providers. English systems for commissioning third sector providers contain both commodified elements (for example formal procurement, provider competition, commissioner-provider separation) and collaborative, relational elements (for example long-term collaboration, reliance on inter-organizational networks). When the two elements conflicted, commissioners and third sector organizations tended to try to work around the commodified elements in order to preserve and develop the collaborative aspects, which suggests that, in practice, they find de-commodified, collaborative methods better adapted to the commissioning of third sector organizations. ABSTRACT When publicly-funded services are outsourced, governments still use multiple governance structures to retain some control over the services provided. Using realist methods the authors systematically compared this aspect of community health activities provided by third sector organizations in six English localities during 2020-2022. Two modes of commissioning coexisted. Commodified commissioning largely embodied Washington consensus models of formal, competitive procurement. A contrasting, collaborative mode of commissioning relied more upon relational, long-term co-operation and networking among organizations. When the two modes conflicted, commissioners often favoured the collaborative mode and sought to adjust their commissioning to make it less commodified.
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Affiliation(s)
- Rod Sheaff
- Peninsular School of Medicine and Dentistry, University of Plymouth, UK
| | | | - Mark Exworthy
- Health Services Management Centre, University of Birmingham, UK
| | - Rebecca Hardwick
- Peninsular School of Medicine and Dentistry, University of Plymouth, UK
| | - Chris Q Smith
- Health Services Management Centre, University of Birmingham, UK
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Gajadien CS, Dohmen PJG, Eijkenaar F, Schut FT, van Raaij EM, Heijink R. Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:125-138. [PMID: 35412163 PMCID: PMC9002227 DOI: 10.1007/s10198-022-01459-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/16/2022] [Indexed: 06/14/2023]
Abstract
In healthcare systems with a purchaser-provider split, contracts are an important tool to define the conditions for the provision of healthcare services. Financial risk allocation can be used in contracts as a mechanism to influence provider behavior and stimulate providers to provide efficient and high-quality care. In this paper, we provide new insights into financial risk allocation between insurers and hospitals in a changing contracting environment. We used unique nationwide data from 901 hospital-insurer contracts in The Netherlands over the years 2013, 2016, and 2018. Based on descriptive and regression analyses, we find that hospitals were exposed to more financial risk over time, although this increase was somewhat counteracted by an increasing use of risk-mitigating measures between 2016 and 2018. It is likely that this trend was heavily influenced by national cost control agreements. In addition, alternative payment models to incentivize value-based health care were rarely used and thus seemingly of lower priority, despite national policies being explicitly directed at this goal. Finally, our analysis shows that hospital and insurer market power were both negatively associated with financial risk for hospitals. This effect becomes stronger if both hospital and insurer have strong market power, which in this case may indicate a greater need to reduce (financial) uncertainties and to create more cooperative relationships.
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Affiliation(s)
- Chandeni S Gajadien
- Dutch Healthcare Authority (Nederlandse Zorgautoriteit; NZa), Utrecht, The Netherlands.
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Peter J G Dohmen
- Dutch Healthcare Authority (Nederlandse Zorgautoriteit; NZa), Utrecht, The Netherlands
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Frank Eijkenaar
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Frederik T Schut
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Erik M van Raaij
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Richard Heijink
- The Council of Public Health & Society (Raad voor Volksgezondheid & Samenleving; RVS), The Hague, The Netherlands
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Holterman S, Hettinga M, Buskens E, Lahr M. Factors Influencing Procurement of Digital Healthcare: A Case Study in Dutch District Nursing. Int J Health Policy Manag 2022; 11:1883-1893. [PMID: 34634888 PMCID: PMC9808215 DOI: 10.34172/ijhpm.2021.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 08/23/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Digital health is considered a promising solution in keeping health care accessible and affordable. However, implementation is often complex and sustainable funding schemes are lacking. Despite supporting policy, scaling up innovative forms of health care progresses much slower than intended in Dutch national framework agreements. The aim of this study is to identify factors that influence the procurement of digital health particular in district nursing. METHODS A case study approach was used, in which multiple stakeholder perspectives are compared using thematic framework analysis. The case studied was the procurement of digital health in Dutch district nursing. Literature on implementation of digital health, public procurement and payment models was used to build the analytic framework. We analysed fourteen interviews (secondary data), two focus groups organised by the national task force procurement and eight governmental and third-party reports. RESULTS Five themes emerged from the analysis: 1) rationale 2) provider-payer relationship, 3) resources, 4) evidence, and 5) the payment model. Per theme a number of factors were identified, mostly related to the design and functioning of the Dutch health system and to the implementation process at providers' side. CONCLUSION This study identified factors influencing the procurement of digital health in Dutch district nursing. The findings, however, are not unique for digital health, district nursing or the Dutch health system. The results presented will support policy makers, and decision makers to improve procurement of digital health. Investing in better relationships between payer and care provider organisations and professionals is an important next step towards scaling digital health.
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Affiliation(s)
- Sander Holterman
- Health Technology Assessment Unit, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
- Research Group IT Innovations in Healthcare, Windesheim University of Applied Sciences, Zwolle, The Netherlands
| | - Marike Hettinga
- Research Group IT Innovations in Healthcare, Windesheim University of Applied Sciences, Zwolle, The Netherlands
| | - Erik Buskens
- Health Technology Assessment Unit, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Maarten Lahr
- Health Technology Assessment Unit, Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
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MacKinnon KR, Mykhalovskiy E, Worthington C, Gómez-Ramírez O, Gilbert M, Grace D. Pay to skip the line: The political economy of digital testing services for HIV and other sexually transmitted infections. Soc Sci Med 2020; 268:113571. [PMID: 33310396 DOI: 10.1016/j.socscimed.2020.113571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 12/26/2022]
Abstract
The value of digital healthcare has been lauded in Canada at local, provincial, and national levels. Digital medicine is purported to enhance patient access to care while promising cost savings. Using institutional ethnography, we examined the potential for publicly funded digital testing for HIV and other sexually transmitted infections (STI) in Ontario, Canada. Our analyses draw from 23 stakeholder interviews with healthcare professionals conducted between 2019 and 2020, and textual analyses of government documents and private, for-profit digital healthcare websites. We uncovered a "two-tiered" system whereby private digital STI testing services enable people with economic resources to "pay to skip the line" queuing at public clinics and proceed directly to provide samples for diagnostics at local private medical labs. In Ontario, private lab corporations compete for fee-for-service contracts with government, which in turn organises opportunities for market growth when more patient samples are collected vis-à-vis digital testing. However, we also found that some infectious disease specimens (e.g., HIV) are re-routed for analysis at government public health laboratories, who may be unable to manage the increase in testing volume associated with digital STI testing due to state budget constraints. Our findings on public-private laboratory funding disparities thus discredit the claims that digital healthcare necessarily generates cost savings, or that it enhances patients' access to care. We conclude that divergent state funding relations together with the creeping privatisation of healthcare within this "universal" system coordinate the conditions through which private corporations capitalise from digital STI testing, compounding patient access inequities. We also stress that our findings bring forth large scale implications given the context of the global COVID-19 pandemic, the rapid diffusion of digital healthcare, together with significant novel coronavirus testing activities initiated by private industry.
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Affiliation(s)
- Kinnon R MacKinnon
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada; School of Social Work, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Eric Mykhalovskiy
- Department of Sociology, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Catherine Worthington
- School of Public Health & Social Policy, University of Victoria, Victoria, BC, V8W 2Y2, Canada
| | - Oralia Gómez-Ramírez
- BC Centre for Disease Control, 655 W 112nd Ave, Vancouver, BC, V5Z 4R4, Canada; School of Population and Public Health, The University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Mark Gilbert
- BC Centre for Disease Control, 655 W 112nd Ave, Vancouver, BC, V5Z 4R4, Canada; School of Population and Public Health, The University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Daniel Grace
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.
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Steenkamer B, Drewes H, Putters K, van Oers H, Baan C. Reorganizing and integrating public health, health care, social care and wider public services: a theory-based framework for collaborative adaptive health networks to achieve the triple aim. J Health Serv Res Policy 2020; 25:187-201. [PMID: 32178546 DOI: 10.1177/1355819620907359] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Population health management (PHM) refers to large-scale transformation efforts by collaborative adaptive health networks that reorganize and integrate services across public health, health care, social care and wider public services in order to improve population health and quality of care while at the same time reducing cost growth. However, a theory-based framework that can guide place-based approaches towards a comprehensive understanding of how and why strategies contribute to the development of PHM is lacking, and this review aims to contribute to closing this gap by identifying the key components considered to be key to successful PHM development. METHODS We carried out a scoping realist review to identify configurations of strategies (S), their outcomes (O), and the contextual factors (C) and mechanisms (M) that explain how and why these outcomes were achieved. We extracted theories put forward in included studies and that underpinned the formulated strategy-context-mechanism-outcome (SCMO) configurations. Iterative axial coding of the SCMOs and the theories that underpin these configurations revealed PHM themes. RESULTS Forty-one studies were included. Eight components were identified: social forces, resources, finance, relations, regulations, market, leadership, and accountability. Each component consists of three or more subcomponents, providing insight into (1) the (sub)component-specific strategies that accelerate PHM development, (2) the necessary contextual factors and mechanisms for these strategies to be successful and (3) the extracted theories that underlie the (sub)component-specific SCMO configurations. These theories originate from a wide variety of scientific disciplines. We bring these (sub)components together into what we call the Collabroative Adaptive Health Network (CAHN) framework. CONCLUSIONS This review presents the strategies that are required for the successful development of PHM. Future research should study the applicability of the CAHN framework in practice to refine and enrich identified relationships and identify PHM guiding principles.
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Affiliation(s)
- Betty Steenkamer
- Researcher, Tranzo, Tilburg School of Social and Behavioural Sciences, Tilburg University, the Netherlands
| | - Hanneke Drewes
- Senior Researcher, Department of Quality of Care and Health Economics, National Institute for Public Health and the Environment (RIVM), the Netherlands
| | - Kim Putters
- Professor, Erasmus School of Health Policy & Management, Erasmus University, the Netherlands.,Director, The Netherlands Institute for Social Research, the Netherlands
| | - Hans van Oers
- Professor, Tranzo, Tilburg School of Social and Behavioural Sciences, Tilburg University, the Netherlands.,Chief Science Officer, National Institute for Public Health and the Environment (RIVM), the Netherlands
| | - Caroline Baan
- Professor, Tranzo, Tilburg School of Social and Behavioural Sciences, Tilburg University, the Netherlands.,Chief Science Officer, National Institute for Public Health and the Environment (RIVM), the Netherlands
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Dohmen PJG, van Raaij EM. A new approach to preferred provider selection in health care. Health Policy 2018; 123:300-305. [PMID: 30249448 DOI: 10.1016/j.healthpol.2018.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 08/24/2018] [Accepted: 09/08/2018] [Indexed: 11/16/2022]
Abstract
In January 2015 Zilveren Kruis, the largest health insurer in The Netherlands, engaged in a new three-year, unlimited volume contract with five carefully selected providers of cataract surgery. Zilveren Kruis used a novel method, designed to identify the top expert providers in a certain discipline. This procedure for provider selection uses the principles of Best Value Procurement (BVP), and puts the provider in charge of defining key performance indicators for health care quality. The procedure empowers the professional and acknowledges that the provider, not the purchaser, is the true expert in defining what is high quality care. This new approach focuses purely on provider selection and is thus complementary to innovations in health care reimbursement, such as value-based hospital purchasing or outcome-based financing. We describe this novel approach to preferred provider selection and show how it makes affordable quality the core topic in negotiations with providers.
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Affiliation(s)
- Peter J G Dohmen
- Rotterdam School of Management, Erasmus University, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands; Erasmus School of Health Policy and Management, Erasmus University, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands.
| | - Erik M van Raaij
- Rotterdam School of Management, Erasmus University, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands; Erasmus School of Health Policy and Management, Erasmus University, Burgemeester Oudlaan 50, 3062 PA Rotterdam, the Netherlands.
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7
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Steenkamer B, Baan C, Putters K, van Oers H, Drewes H. Population health management guiding principles to stimulate collaboration and improve pharmaceutical care. J Health Organ Manag 2018; 32:224-245. [PMID: 29624140 PMCID: PMC5925855 DOI: 10.1108/jhom-06-2017-0146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/06/2017] [Accepted: 01/10/2018] [Indexed: 11/17/2022]
Abstract
Purpose A range of strategies to improve pharmaceutical care has been implemented by population health management (PHM) initiatives. However, which strategies generate the desired outcomes is largely unknown. The purpose of this paper is to identify guiding principles underlying collaborative strategies to improve pharmaceutical care and the contextual factors and mechanisms through which these principles operate. Design/methodology/approach The evaluation was informed by a realist methodology examining the links between PHM strategies, their outcomes and the contexts and mechanisms by which these strategies operate. Guiding principles were identified by grouping context-specific strategies with specific outcomes. Findings In total, ten guiding principles were identified: create agreement and commitment based on a long-term vision; foster cooperation and representation at the board level; use layered governance structures; create awareness at all levels; enable interpersonal links at all levels; create learning environments; organize shared responsibility; adjust financial strategies to market contexts; organize mutual gains; and align regional agreements with national policies and regulations. Contextual factors such as shared savings influenced the effectiveness of the guiding principles. Mechanisms by which these guiding principles operate were, for instance, fostering trust and creating a shared sense of the problem. Practical implications The guiding principles highlight how collaboration can be stimulated to improve pharmaceutical care while taking into account local constraints and possibilities. The interdependency of these principles necessitates effectuating them together in order to realize the best possible improvements and outcomes. Originality/value This is the first study using a realist approach to understand the guiding principles underlying collaboration to improve pharmaceutical care.
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Affiliation(s)
- Betty Steenkamer
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilberg, The Netherlands
| | - Caroline Baan
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilberg, The Netherlands
- Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Kim Putters
- Department of Health Care Governance, Institute for Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- The Netherlands Institute for Social Research, The Hague, The Netherlands
| | - Hans van Oers
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilberg, The Netherlands
- Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Hanneke Drewes
- Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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Fichera E, Gravelle H, Pezzino M, Sutton M. Quality target negotiation in health care: evidence from the English NHS. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:811-822. [PMID: 26362867 DOI: 10.1007/s10198-015-0723-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 08/19/2015] [Indexed: 06/05/2023]
Abstract
We examine how public sector third-party purchasers and hospitals negotiate quality targets when a fixed proportion of hospital revenue is required to be linked to quality. We develop a bargaining model linking the number of quality targets to purchaser and hospital characteristics. Using data extracted from 153 contracts for acute hospital services in England in 2010/2011, we find that the number of quality targets is associated with the purchaser's population health and its budget, the hospital type, whether the purchaser delegated negotiation to an agency, and the quality targets imposed by the supervising regional health authority.
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Affiliation(s)
- Eleonora Fichera
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Mario Pezzino
- Economics, School of Social Sciences, University of Manchester, Manchester, UK.
| | - Matt Sutton
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
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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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Sheaff R, Charles N, Mahon A, Chambers N, Morando V, Exworthy M, Byng R, Mannion R, Llewellyn S. NHS commissioning practice and health system governance: a mixed-methods realistic evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundBy 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’).ObjectivesTo: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers.DesignMixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically.ResultsIn the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners.ConclusionsCommissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rod Sheaff
- School of Government, Plymouth University, Plymouth, UK
| | - Nigel Charles
- School of Government, Plymouth University, Plymouth, UK
| | - Ann Mahon
- Manchester Business School, Manchester University, Manchester, UK
| | - Naomi Chambers
- Manchester Business School, Manchester University, Manchester, UK
| | | | | | - Richard Byng
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Sue Llewellyn
- Manchester Business School, Manchester University, Manchester, UK
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Krachler N, Greer I. When does marketisation lead to privatisation? Profit-making in English health services after the 2012 Health and Social Care Act. Soc Sci Med 2015; 124:215-23. [DOI: 10.1016/j.socscimed.2014.11.045] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Kristensen SR, McDonald R, Sutton M. Should pay-for-performance schemes be locally designed? Evidence from the Commissioning for Quality and Innovation (CQUIN) Framework. J Health Serv Res Policy 2014; 18:38-49. [PMID: 24121835 DOI: 10.1177/1355819613490148] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES It is increasingly recognized that the design characteristics of pay-for-performance schemes are important in determining their impact. One important but under-studied design aspect is the extent to which pay-for-performance schemes reflect local priorities. The English Department of Health White Paper High Quality Care for All introduced a Commissioning for Quality and Innovation (CQUIN) Framework from April 2009, under which local commissioners and providers were required to negotiate and implement an annual pay-for-performance scheme. In 2010/2011, these schemes covered 1.5% (£ 1.0 bn) of NHS expenditure. Local design was intended to offer flexibility to local priorities and generate local enthusiasm, while retaining good design properties of focusing on outcomes and processes with a clear link to quality, using established indicators where possible, and covering three key domains of quality (safety; effectiveness; patient experience) and innovation. We assess the extent to which local design achieved these objectives. METHODS Quantitative analysis of 337 locally negotiated CQUIN schemes in 2010/2011, along with qualitative analysis of 373 meetings (comprising 800 hours of observation) and 230 formal interviews (audio-recorded and transcribed verbatim) with NHS staff in 12 case study sites. RESULTS The local development process was successful in identifying variation in local needs and priorities for quality improvement but the involvement of frontline clinical staff was insufficient to generate local enthusiasm around the schemes. The schemes did not in general live up to the requirements set by the Department of Health to ensure that local schemes addressed the original objectives for the CQUIN framework. CONCLUSIONS While there is clearly an important case for local strategic and clinical input into the design of pay-for-performance schemes, this should be kept separate from the technical design process, which involves defining indicators, agreeing thresholds, and setting prices. These tasks require expertise that is unlikely to exist in each locality. The CQUIN framework potentially offered an opportunity to learn how technical design influenced outcome but due to the high degree of local experimentation and little systematic collection of key variables, it is difficult to derive lessons from this unstructured experiment about the impact and importance of different technical design factors on the effectiveness of pay-for-performance. Balancing the policy goal of localism with the objective of improving patient outcomes leads us to conclude that a somewhat firmer national framework would be preferable to a fully locally designed framework.
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Affiliation(s)
- Søren Rud Kristensen
- Research Fellow, Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, UK
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Trybou J, Gemmel P, Annemans L. How to govern physician-hospital exchanges: contractual and relational issues in Belgian hospitals. J Health Serv Res Policy 2014; 19:145-152. [PMID: 24470533 DOI: 10.1177/1355819613518765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Our aim was to investigate contractual mechanisms in physician-hospital exchanges. The concepts of risk-sharing and the nature of physician-hospital exchanges - transactional versus relational - were studied. METHODS Two qualitative case studies were performed in Belgium. Hospital executives and physicians were interviewed to develop an in-depth understanding of contractual and relational issues that shape physician-hospital contracting in acute care hospitals. The underlying theoretical concepts of agency theory and social exchange theory were used to analyse the data. RESULTS Our study found that physician-hospital contracting is highly complex. The contract is far more than an economic instrument governing financial aspects. The effect of the contract on the nature of exchange - whether transactional or relational - also needs to be considered. While it can be argued that contractual governance methods are increasingly necessary to overcome the difficulties that arise from the fragmented payment framework by aligning incentives and sharing financial risk, they undermine the necessary relational governance. Relational qualities such as mutual trust and an integrative view on physician-hospital exchanges are threatened, and may be difficult to sustain, given the current fragmentary payment framework. CONCLUSIONS Since health care policy makers are increasing the financial risk borne by health care providers, it can be argued that this also increases the need to share financial risk and to align incentives between physician and hospital. However, our study demonstrates that while economic alignment is important in determining physician-hospital contracts, the corresponding impact on working relationships should also be considered. Moreover, it is important to avoid a relationship between hospital and physician predominantly characterized by transactional exchanges thereby fostering an unhealthy us-and-them divide and mentality. Relational exchange is a valuable alternative to contractual exchange, stimulating an integrated hospital-physician relationship. Unfortunately, the fragmented payment framework characterized by unaligned incentives is perceived as an obstacle to realize effective collaboration.
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Affiliation(s)
- Jeroen Trybou
- Research Fellow in Health Services Research, Department of Public Health, Ghent University, Belgium
| | - Paul Gemmel
- Professor of Healthcare & Services Management, Department of Management, Innovation and Entrepreneurship, Ghent University, Belgium
| | - Lieven Annemans
- Professor of Health Economics, Department of Public Health, Ghent University, Belgium Professor of Health Economics, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Belgium
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Abstract
BACKGROUND Over the past three decades, a limited range of market like mechanisms have been introduced into the hierarchically structured English National Health Service ('NHS'), which is a nationally tax funded, budget limited healthcare system, with access to care for all, producing structures known as a quasi market. Recently, the Health and Social Care Act 2012 ('HSCA') has been enacted, introducing further market elements. The paper examines the theory and effects of these market mechanisms. METHODS Using neo-classical economics as a primary theoretical framework, as well as new institutional economics and socio-legal theory, the paper first examines the fundamental elements of markets, comparing these with the operation of authority and resource allocation employed in hierarchical structures. Second, the paper examines the application of market concepts to the delivery of healthcare, drawing out the problems which economic and socio-legal theories predict are likely to be encountered. Third, the paper discusses the research evidence concerning the operation of the quasi market in the English NHS. This evidence is provided by research conducted in the UK which uses economic and socio-legal logic to investigate the operation of the economic aspects of the NHS quasi market. Fourth, the paper provides an analysis of the salient elements of the quasi market regime amended by the HSCA 2012. RESULTS It is not possible to construct a market conforming to classical economic principles in respect of healthcare. Moreover, it is not desirable to do so, as goals which markets cannot deliver (such as fairness of access) are crucial in England. Most of the evidence shows that the quasi market mechanisms used in the English NHS do not appear to be effective either. This finding should be seen in the light of the fact that the operation of these mechanisms has been significantly affected by the national political (i.e. continuingly hierarchical) and budgetary context in which they are operating. CONCLUSION The organisational structures of a hierarchy are more appropriate for the delivery of healthcare in the English NHS.
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Affiliation(s)
- Pauline Allen
- London School of Hygiene and Tropical Medicine, London, UK.
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Porter A, Mays N, Shaw SE, Rosen R, Smith J. Commissioning healthcare for people with long term conditions: the persistence of relational contracting in England's NHS quasi-market. BMC Health Serv Res 2013; 13 Suppl 1:S2. [PMID: 23735008 PMCID: PMC3663656 DOI: 10.1186/1472-6963-13-s1-s2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market. Methods We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents. Results In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services. In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach. Conclusions Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.
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Affiliation(s)
- Alison Porter
- College of Medicine, Swansea University SA2 8PP, UK.
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Hughes D, Allen P, Doheny S, Petsoulas C, Vincent-Jones P. Co-operation and conflict under hard and soft contracting regimes: case studies from England and Wales. BMC Health Serv Res 2013; 13 Suppl 1:S7. [PMID: 23734604 PMCID: PMC3663652 DOI: 10.1186/1472-6963-13-s1-s7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background This paper examines NHS secondary care contracting in England and Wales in a period which saw increasing policy divergence between the two systems. At face value, England was making greater use of market levers and utilising harder-edged service contracts incorporating financial penalties and incentives, while Wales was retreating from the 1990s internal market and emphasising cooperation and flexibility in the contracting process. But there were also cross-border spill-overs involving common contracting technologies and management cultures that meant that differences in on-the-ground contracting practices might be smaller than headline policy differences suggested. Methods The nature of real-world contracting behaviour was investigated by undertaking two qualitative case studies in England and two in Wales, each based on a local purchaser/provider network. The case studies involved ethnographic observations and interviews with staff in primary care trusts (PCTs) or local health boards (LHBs), NHS or Foundation trusts, and the overseeing Strategic Health Authority or NHS Wales regional office, as well as scrutiny of relevant documents. Results Wider policy differences between the two NHS systems were reflected in differing contracting frameworks, involving regional commissioning in Wales and commissioning by either a PCT, or co-operating pair of PCTs in our English case studies, and also in different oversight arrangements by higher tiers of the service. However, long-term relationships and trust between purchasers and providers had an important role in both systems when the financial viability of organisations was at risk. In England, the study found examples where both PCTs and trusts relaxed contractual requirements to assist partners faced with deficits. In Wales, news of plans to end the purchaser/provider split meant a return to less precisely-specified block contracts and a renewed concern to build cooperation between LHB and trust staff. Conclusions The interdependency of local purchasers and providers fostered long-term relationships and co-operation that shaped contracting behaviour, just as much as the design of contracts and the presence or absence of contractual penalties and incentives. Although conflict and tensions between contracting partners sometimes surfaced in both the English and Welsh case studies, cooperative behaviour became crucial in times of trouble.
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Affiliation(s)
- David Hughes
- Department of Public Health & Policy Studies, Swansea University, UK.
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Coleman A, Checkland K, McDermott I, Harrison S. The limits of market-based reforms in the NHS: the case of alternative providers in primary care. BMC Health Serv Res 2013; 13 Suppl 1:S3. [PMID: 23735051 PMCID: PMC3663654 DOI: 10.1186/1472-6963-13-s1-s3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Historically, primary medical care in the UK has been delivered by general practitioners who are independent contractors, operating under a contract, which until 2004 was subject to little performance management. In keeping with the wider political impetus to introduce markets and competition into the NHS, reforms were introduced to allow new providers to bid for contracts to provide primary care services in England. These contracts known as ‘Alternative Provider Medical Services’, were encouraged by two centrally-driven rounds of procurement (2007/8 and 2008/9). This research investigated the commissioning and operation of such Alternative Providers of Primary Care (APPCs). Methods Two qualitative case studies were undertaken in purposively sampled English Primary Care Trusts (PCTs) and their associated APPCs over 14 months (2009-10). We observed 65 hours of meetings, conducted 23 interviews with PCT and practice staff, and gathered relevant associated documentation. Results and conclusions We found that the procurement and contracting process was costly and time-consuming. Extensive local consultation was undertaken, and there was considerable opposition in some areas. Many APPCs struggled to build up their patient list sizes, whilst over-performing on walk-in contracts. Contracting for APPCs was ‘transactional’, in marked contrast to the ‘relational’ contracting usually found in the NHS, with APPCs subject to tight performance management. These complicated and costly processes contrast to those experienced by traditionally owned GP partnerships. However, managers reported that the perception of competition had led existing practices to improve their services. The Coalition Government elected in 2010 is committed to ‘Any Qualified Provider’ of secondary care, and some commentators argue that this should also be applied to primary care. Our research suggests that, if this is to happen, a debate is needed about the operation of a market in primary care provision, including the trade-offs between transparent processes, fair procurement, performance assurance and cost.
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Affiliation(s)
- Anna Coleman
- Health Policy, Politics & Organisation research group (HiPPO), Centre for Primary Care, Institute of Population Health, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
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Jones L, Exworthy M, Frosini F. Implementing market-based reforms in the English NHS: bureaucratic coping strategies and social embeddedness. Health Policy 2013; 111:52-9. [PMID: 23601569 DOI: 10.1016/j.healthpol.2013.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 03/13/2013] [Accepted: 03/18/2013] [Indexed: 10/27/2022]
Abstract
This paper reports findings from an ethnographic study that explored how market-based policies were implemented in one local health economy in England. We identified a number of coping strategies employed by local agents in response to multiple, rapidly changing and often contradictory central policies. These included prioritising the most pressing concern, relabelling existing initiatives as new policy and using new policies as a lever to realise local objectives. These coping strategies diluted the impact of market-based reforms. The impact of market-based policies was also tempered by the persistence of local social relationships in the form of 'sticky' referral patterns and agreements between organisations not to compete. Where national market-based policies disrupted local relationships they produced unintended consequences by creating an adversarial environment that prevented collaboration.
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Affiliation(s)
- Lorelei Jones
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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