Transforming health care: the policy and politics of service reconfiguration in the UK's four health systems

Analyzing the 20-year declining trend of hospital length-of-stay in European countries with different healthcare systems and reimbursement models

The study aims to investigate the last 20-year (2000-2019) of hospital length of stay (LOS) trends and their association with different healthcare systems (HS) among 25 European countries. A panel dataset was created using secondary data from Eurostat and Global Burden of Disease study databases, with dependent and control variables aggregated at the national level over a period of 20 years. A time trend analysis was conducted using a weighted least squares model for panel data to investigate the association between LOS, HS models [National Health Service (NHS), National Health Insurance, Social Health Insurance (SHI), and Etatist Social Health Insurance], healthcare reimbursement schemes [Prospective Global Budget (PGB), Diagnosis Related Groups (DRG), and Procedure Service Payment (PSP)], and control variables. The study showed a reduction of average LOS from 9.20 days in 2000 to 7.24 in 2019. SHI was associated with a lower LOS compared to NHS (b = - 0.6327, p < 0.05). Both DRG (b = 1.2399, p < 0.05) and PSP (b = 1.1677, p < 0.05) reimbursement models were positively associated with LOS compared to PGB. Our results confirmed the downward trend of LOS in the last 20 years, its multifactorial nature, and the influence of the SHI model of HS. This could be due to the financial incentives present in fee-for-service payment models and the role of competition in creating a market for healthcare services. These results offer insight into the factors influencing healthcare utilization and can inform the design of more effective, efficient, and sustainable HS.

For better or worse: Governing healthcare organisations in times of financial distress

Due to processes of financialisation, financial parties increasingly penetrate the healthcare domain and determine under which conditions care is delivered. Their influence becomes especially visible when healthcare organisations face financial distress. By zooming-in on two of such cases, we come to know more about the considerations, motives and actions of financial parties in healthcare. In this research, we were able to examine the social dynamics between healthcare executives, banks and health insurers involved in a Dutch hospital and mental healthcare organisation on the verge of bankruptcy. Informed by interviews, document analysis and translation theory, we reconstructed the motives and strategies of executives, banks and health insurers and show how they play a crucial role in decision-making processes surrounding the survival or downfall of healthcare organisations. While parties are bound by legislation and company procedures, the outcome of financial distress can still be influenced. Much depends on how executives are perceived by financial stakeholders and how they deal with threats of destabilisation of the network. We further draw attention to the consequences of financialisation processes on the practices of healthcare organisations in financial distress.

Governing healthcare: the uses and limits of governmentality in the National Health Service in England

Using examples from the National Health Service in England, this paper illustrates key features of contemporary healthcare governance: the way decisions are hidden in places that are 'in between' and 'out of reach'; the enrolment of doctors in governing; and the important role played by 'boring things', such as power point slides, flow charts, and forms. The essay shows how anthropological proximity and perspectives can extend and deepen understanding of contemporary political power. It does this firstly by showing the importance of agency in the operation of governmentality, and secondly by illuminating the limits of governmentality. The different elements of governing assemblages, such as global management experts, medical leaders, forms of knowledge and analytical technologies, are brought together through the strategic act of framing. Frames are contested and resisted, requiring more visible forms of control.

Health policy under the microscope: a micro policy design perspective

The comparative study of health policy has focused mainly on the macro-structural dimensions of health systems and reforms that have sought to change these organizational arrangements. Thus, a great deal of attention has been paid to the multiple models of insurance against sickness risks and various modes of organizing and financing healthcare providers. However, little attention has been paid to policy tools and policy design in the health policy domain. This research gap largely impedes a focus on the micro (granular) dimension of health policy, although this is the level at which health policies impact reality and thus deliver progress toward the expected goals. Such a focus on the micro dimension could not only allow a finer-grained comparison of how health systems work but also shed light on how capable health policies are of achieving the expected outcomes. This paper fills this gap by presenting an analytical framework capable of illuminating the granular dimension of policy design (the instrumental delivery package) and shows the analytical relevance of the framework by applying it to the designs of maximum waiting time guarantee and vaccination mandate policies.

A comparative overview of health and social care policy for older people in England and Scotland, United Kingdom (UK)

BACKGROUND

Responsibility for health and social care was devolved to Scotland in 1999 with evidence of diverging policy and organisation of care compared to England. This paper provides a comparative overview of major health and social care policies in England and Scotland published between 2011 and 2023 relating to the care of older people.

METHODS

We searched United Kingdom (UK) and Scotland government websites for macro-level policy documents between 2011 and 2023 relating to the health and social care of older people (aged 65+). Data were extracted and emergent themes were summarised according to Donabedian's structure-process-outcome model.

RESULTS

We reviewed 27 policies in England and 28 in Scotland. Four main policy themes emerged that were common to both countries. Two related to the structure of care: integration of care and adult social care reform. Two related to service delivery/processes of care: prevention and supported self-management and improving mental health care. Cross-cutting themes included person-centred care, addressing health inequalities, promoting use of technology, and improving outcomes.

CONCLUSION

Despite differences in the structure of care, including more competition, financial incentivization, and consumer-based care in England compared to Scotland, there are similarities in policy vision around delivery/processes of care (e.g. person-centred care) and performance and patient outcomes. Lack of UK-wide health and social care datasets hinders evaluation of policies and comparison of outcomes between both countries.

Positive association between social capital and the quality of health care service: A cross-sectional study

BACKGROUND

Social capital is an acknowledged theoretical concept in work environment research focusing on collective resources that arise from social networks between employees in the workplace. Social capital is divided into bonding (in the work unit), bridging (between work units), and linking social capital (between the work units and management). However, only a few studies have investigated the relationship between social capital and the quality of health care, which is the key outcome of hospital services.

OBJECTIVE

We investigated the associations between bonding, bridging and two types of linking social capital with the self-reported quality of health care services among Danish hospital employees. Next, we directly compared how social capital, workload and work pace each affected the quality of health care.

DESIGN

A cross-sectional study at Regional Hospital West Jutland, Denmark.

DATA

Questionnaire data were collected from 1589 Danish hospital employees. We used validated scales for social capital, workload, and work pace and self-developed scales for clinical quality, quality of patient involvement, and overall professional quality.

METHODS

Binary logistic regression analyses were conducted.

RESULTS

The analyses showed significant, positive associations of bonding and bridging social capital with all types of quality and negative associations between workload and all types of quality. The work pace was negatively associated with clinical quality. When covariates were included in the model, the associations remained statistically significant and showed no decrease in odds ratios. The marginal effects showed that when bonding and bridging social capital were increased by a single scale point, the predicted probability for a high clinical quality increased by an average of 0.5 percentage points. This increase corresponds to a change in the predicted probability of self-reported high clinical quality from 10% for the lowest reported bridging social capital to 54% for the highest reported bridging social capital. For workload and work pace, the effects were -0.2 and -0.3 percentage points, respectively.

DISCUSSION & CONCLUSIONS

This study adds to the literature on positive work environment factors by focusing on social capital and the importance of well-functioning relationships within and especially between hospital units for high-quality health care. Hence, bridging and bonding social capital should be included in theoretical frameworks, as well as in hospital strategies and work environment guidelines to potentially improve the quality of health care services. However, further studies are needed to develop and test the effects of specific social capital interventions on the quality of health care services.

Observations from a small country: mental health policy, services and nursing in Wales

Wales is a small country, with an ageing population, high levels of population health need and an economy with a significant reliance on public services. Its health system attracts little attention, with analyses tending to underplay the differences between the four countries of the UK. This paper helps redress this via a case study of Welsh mental health policy, services and nursing practice. Distinctively, successive devolved governments in Wales have emphasised public planning and provision. Wales also has primary legislation addressing sustainability and future generations, safe nurse staffing and rights of access to mental health services. However, in a context in which gaps always exist between national policy, local services and face-to-face care, evidence points to the existence of tension between Welsh policy aspirations and realities. Mental health nurses in Wales have produced a framework for action, which describes practice exemplars and looks forward to a secure future for the profession. With policy, however enlightened, lacking the singular potency to bring about intended change, nurses as the largest of the professional groups involved in mental health care have opportunities to make a difference in Wales through leadership, influence and collective action.

The Impact of Health Investment on Industrial Structure: “Spillover” or “Crowding Out”?—Evidence From Emerging Market Countries

Using national dynamic panel data from 21 emerging markets between 1999 and 2020 and bidirectional fixed effect and threshold regression methods, this paper evaluated the impact of health investment on industrial structure upgrading from two aspects of economic output and economic structure. The results showed that: (1) public health investment and private health investment have a crowding out effect on the added value of primary and secondary industries, and the crowding out effect of public health investment is greater than that of private health investment; (2) Public health investment and private health investment have a spillover effect on the added value of the tertiary industry, and the spillover effect of public health investment is greater than that of private health investment; (3) Both public and private health investment contribute to the transfer of the labor force to the tertiary industry, and tests showed the baseline regression results were robust and reliable; (4) The relationship between health investment and industrial structure upgrading was non-linear. As per capital GDP increases, the inhibition effect of public health investment on industrial structure upgrading gradually weakens whilst the promotion effect of private health investment on industrial structure upgrading gradually increases. The results of this study clarify how health investment affects industrial structure, and offers new guidance for health investment policy formulation in emerging market countries.

Changing health care with, for, or against the public: an empirical investigation into the place of the public in health service reconfiguration

OBJECTIVES

This study sought to understand the different approaches taken to involving the public in service reconfiguration in the four United Kingdom health systems.

METHODS

This was a multi-method study involving policy document analysis and qualitative semi-structured interviews in England, Northern Ireland, Scotland and Wales.

RESULTS

Despite the diversity of local situations, interview participants tended to use three frames within which they understood the politics of service reconfigurations: an adversarial approach which assumed conflict over scarce resources (change against the public); a communications approach which defined the problem as educating the public on the desirability of change (change for the public); and a collaborative approach which attempted to integrate the public early into discussions about the shape and nature of desirable services (change with the public). These three framings involved different levels of managerial time, energy, and resources and called on different skill sets, most notably marketing and communications for the communications approach and community engagement for the collaborative approach.

CONCLUSIONS

We argue that these framings of public involvement co-exist within organisations. Health system leaders, in framing service reconfiguration as adversarial, communicative or collaborative, are deciding between conceptions of the relationship between health care organisations and their publics in ways that shape the nature of the debates that follow. Understanding the reasons why organisations adopt these frames would be a fruitful way to advance both theory and practice.

The 'nuts and bolts' of including service users and carers in the recruitment of health and social work students in an English university-An interdisciplinary critique

Background

The literature regarding inclusion of service users and carers (SUACs) in the recruitment processes for future health and social work professionals has primarily presented such inclusion as positive for all. This study is novel in its exploration of the detail of SUACs' involvement and in its reach across a whole university department of health and social care disciplines.

Objective

To examine the detail of ways in which SUACs were actually involved in student selection and whether they have any real influence on recruitment decisions.

Method

This co‐produced study took place in an English university. A qualitative, semi‐structured interviewing approach was undertaken with 12 staff across social work, nursing, occupational therapy, physiotherapy, paramedicine and physician associate disciplines. Thematic analysis was employed independently with both researchers agreeing resultant themes.

Findings

A range of recruitment activities which included SUACs were found, evidencing both full and partial involvement in decision making. Nine themes emerged—The quality of SUACs' inclusion; Understanding reasons for including SUACs; SUACs being more knowledgeable than academic staff; SUACs influencing final decisions; The high expectations of candidates by SUACs; SUACs' need for training; Marketization and scepticism; and Logistics and the presumption of ableism.

Conclusions

Transparent protocols are essential if SUACs are to be equitably included in student recruitment processes. A shared model of SUACs' inclusion should be attainable across disciplines, even if the ‘nuts and bolts’ of recruitment processes vary.

Patient or Public Contribution

This work was co‐produced with a SUACs' group from conception and design through to fieldwork and write‐up.

Power and Purchasing: Why Strategic Purchasing Fails

Policy Points Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness.

CONTEXT

Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing.

METHODS

We conducted three in-depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such as strategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years.

FINDINGS

No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry.

CONCLUSIONS

Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create.

Patient and public involvement in priority-setting decisions in England's Transforming NHS: An interview study with Clinical Commissioning Groups in South London sustainability transformation partnerships

BACKGROUND

Patient and public involvement (PPI) in health-care commissioning decisions has always been a contentious issue. However, the current moves towards Sustainability and Transformation Partnerships (STPs) in England's NHS are viewed as posing the risk of reducing the impact of current structures for PPI.

OBJECTIVE

To understand how different members in clinical commissioning groups (CCGs) understand PPI as currently functioning in their decision-making practices, and the implications of the STPs for it.

DESIGN

Thematic analysis of 18 semi-structured interviews with CCG governing body voting members (e.g. clinicians and lay members), non-voting governing body members (e.g. Healthwatch representatives) and CCG staff with roles focussed on PPI, recruited from CCGs in South London STPs.

RESULTS

There are contestations amongst CCG members regarding not only what PPI is, but also the role that it currently plays and could play in commissioning decision making in the context of STPs. Three main themes were identified: PPI is 'going out' into the community; PPI as a disruptive power; and PPI as co-production, a 'utopian dream'?

CONCLUSIONS

Long-standing issues distinctive to PPI in NHS prioritization decisions are resurfacing with the moves towards STPs, particularly in relation to contradictions between the rhetoric of 'partnership' and reorganizations that foster more top-down control. The interviews reveal pervasive distrusts across a number of levels that are counterproductive to the collaborations upon which STPs rely. And it is argued that such distrust and contestations will continue until a formalized space for PPI in STP priority-setting is created.