The politics of medical quality: auditing doctors in the UK and the USA

Is audit research? The relationships between clinical audit and social-research

PURPOSE

Quality has an established history in health care. Audit, as a means of quality assessment, is well understood and the existing literature has identified links between audit and research processes. This paper reviews the relationships between audit and research processes, highlighting how audit can be improved through the principles and practice of social research.

DESIGN/METHODOLOGY/APPROACH

The review begins by defining the audit process. It goes on to explore salient relationships between clinical audit and research, grouped into the following broad themes: ethical considerations, highlighting responsibilities towards others and the need for ethical review for audit; asking questions and using appropriate methods, emphasising transparency in audit methods; conceptual issues, including identifying problematic concepts, such as "satisfaction", and the importance of reflexivity within audit; emphasising research in context, highlighting the benefits of vignettes and action research; complementary methods, demonstrating improvements for the quality of findings; and training and multidisciplinary working, suggesting the need for closer relationships between researchers and clinical practitioners.

FINDINGS

Audit processes cannot be considered research. Both audit and research processes serve distinct purposes.

ORIGINALITY/VALUE

Attention to the principles of research when conducting audit are necessary to improve the quality of audit and, in turn, the quality of health care.

Talking contracts and taking care: managers and professionals in the British National Health Service internal market

This paper draws on audio-recordings of a Health Authority's contract monitoring meetings with hospital providers to examine the nature of interactions between managers and clinical professionals in the British National Health Service internal market. It describes how managers and professionals arrive at a working division of labour, which acknowledges their respective spheres of expertise, but also leaves a space where definitions are contested. There is an interplay of competing managerial and professional discourses which construct problems and proposed solutions in fundamentally non-commensurable ways. Yet only rarely do managers or professionals mount challenges in ways that bring them on to the territory of the other group; rather each group seeks to frame problems to mesh with its special domain of competence. Managers seek to push back the boundaries of professional control by constructing a language and set of practices which will govern the contracting process. But they remain reliant on professionals to mediate between the requirements of contracting and the realities of clinical work. Clinical arguments continue to have high perceived legitimacy for managers, and will often be taken up by hospital managers in negotiations with their Health Authority counterparts. It is argued that the dependency of managers on professionals to make the contracting system work, taken together with the continued social and cultural authority of senior medical consultants, limits managers' ability to control professionals.

The end of professionalism?

Increasingly questions are being raised about the ability of many current health reforms to address the challenges that are facing health systems. We investigate this situation by exploring the role of professionalism in the delivery of health services. In contrast to the dominant approach of considering professionalism as a social phenomenon, professionalism is considered as primarily a task-related phenomenon. The characteristics of the task are identified as being high levels of uncertainty and complexity. These characteristics are shown to lead naturally to the key social features that typify professionalism. Hence, the close link between professionalism and the nature of the task is argued. However, health reforms threaten professionalism. They have been based on considerable dissatisfaction with the performance of professionals as well as the emergence of a number of new challenges. In addition, the reforms have been developed without significant consideration of the central role that professionalism has played, and reformers have adopted a simplified view of the task. Thus, the centrality of professionalism has intrinsically been downgraded. However, this simplification can be shown to be inconsistent with the realities and complexities of health service provision, and thus the downgrading of professionalism is unwarranted. This inconsistency generates many of the conflicts and contradictions being reported. The future of health service reform depends on an effective understanding of the nature of the task, recognition of the central role of professionalism and the development of professional and organisational structures that support each other.

Implementing quality of programmes in three Swedish county councils: the views of politicians, managers and doctors

This articles deals with quality assurance within the Swedish health care system at the regional and local levels. The overriding issue concerns the degree to which changes in Swedish health care in recent years with respect to increased freedom of choice for the individual, the purchaser-provider split and new forms of financial reimbursement have affected quality assurance. Special attention is directed toward the relationship between the political-administrative level in the county councils and the medical profession at the local level. Since political responsibility for health care is strongly decentralized and different organizational solutions can be found, Sweden offers a good opportunity for systematic comparisons within the health care sector. Following an overview of certain national initiatives with regard to the quality of health care, three Swedish county councils are compared. The aim is not to provide a general overview of the situation in Sweden with regard to quality assurance, but to compare the strategies and outcomes in county councils with different organizational configurations. The study is based on 35 interviews conducted in 1995 with health care politicians, health care administrators, hospital directors and clinical department heads. The article concludes that indirect incentives can be very strong factors in affecting care providers' active interest in quality assurance. This interest is aroused when providers feel they are in competition in that the number of patients decreases, or in that their activities are being called into question, such as in the form of discussions about possible structural changes in the county council.

Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting

A number of countries have adopted contracting reforms in which hospitals are placed at financial risk. This risk has stimulated a number of adaptive strategies to achieve organizational success. This paper presents a model of six forms of contracting relationships and reviews the adaptation strategies observed in three health systems: the USA, England and the Netherlands. These strategies include service diversification, improved management information systems, the employment of marketing and contract managers, the use of clinical pathways, case management and concurrent/retrospective review of hospital stays, quality management and quality assurance programs, pre-admission authorization, discharge planning, and physician profiling and participation in management. These adaptive strategies have three implications for managers: increased 'partnering', with purchasers, collaboration with medical staff, and assumption of managed care roles. Two groups of institutions are at risk from the changes in hospital contracting: university teaching hospitals and inner-city hospitals serving socially deprived populations. The paper ends with implications for the education of hospital managers and research on hospital management and adaptation to contracting.

Clinicians into management: the experience in context

This paper interprets the experience of a sample of 60 clinicians becoming involved in formal management, mainly at hospital unit level, in the historical context of changing health service organisation. This includes the introduction of managerialism and the evolution of the NHS into a structured network based around purchaser/provider relationships. The conclusion is that these clinicians are becoming involved in management, and making the personal and social adjustments necessary for this, but in a way that leaves medical culture, and their allegiance to it, at the present largely intact. This is achieved largely through the organisational mechanism of clinical directorates, which promise to function as professional groups from the clinical point of view and as business units from the managerial perspective. An argument is put forward, based on a theoretical view compatible with the data from the clinicians' experience, that this mode of medical involvement in management may operate without undue conflict in the longer term if: (a) clinicians accept the degree of local professional regulation that this model applies; and (b) the conflict between medical need and available resource can be dealt with elsewhere in the system without passing it back to hospitals and clinical directorates. On the other hand it is possible that conflict will increase if the consequences of management control systems and objectives percolate down through the management hierarchy and cross into the medical domain, via clinical directorates.