Measuring competition in primary care-Evidence from Sweden

INTRODUCTION

In many tax-based healthcare systems, policymakers have introduced reforms that promote provider competition with the intention of improving the quality and efficiency. Healthcare competition is usually defined spatially, with local markets often being identified as a circle around each provider. We argue that existing local market definitions can be improved to better capture actual local markets. For pro-competition reforms to potentially lead to the gains envisioned by policymakers, a crucial condition is the actual emergence of competitive markets. However, limited research has been conducted on competition in primary care markets, despite primary care constituting a vital part of a healthcare system.

AIM

The study aims to contribute to the debate on how to define local markets geographically and to examine provider competition in Swedish primary care.

METHODS

A cross-sectional study was conducted using data on all individuals and all primary care providers in Sweden. Local markets were defined as: fixed radius (1 km and 3 km); variable radius; and variable shape-our new local market definition that allows markets to vary in both size and shape. Competition was measured using the Herfindahl-Hirschman index and a count of the number of competitors within the local market.

RESULTS

Fixed radius markets fail to capture variation within and across geographical areas. The variable radius and variable shape markets are similar but do not always identify the same competitors or level of competition. Furthermore, competition levels vary significantly in Swedish primary care. Many providers operate in monopoly markets, whereas others face high competition.

CONCLUSIONS

While the variable shape approach has the potential to better capture actual markets and more accurately identify competitors, further analyses are needed. Moreover, Swedish policymakers are advised to decide whether to still pursue competition and if so, take measures to improve local market conditions in monopolies.

Expectations of radiographer reporting roles: A multimethod evaluation across a single imaging network

INTRODUCTION

Prior studies have demonstrated inconsistent development and utilisation of radiographers in the reporting of radiographs, and there is ongoing consideration of the level at which such radiographers should be educated to and operating at. This study aimed to explore and evaluate expectation and utilisation of radiographers currently, or training in, reporting in projection radiography across one integrated care system (ICS).

METHODS

A multi-method approach was utilised, with document analysis of projection radiography reporting role job descriptions and person specifications and an online survey of managers and clinical leads. A single ICS in the north of England formed the setting for the study.

RESULTS

This study demonstrated variation in implementation and utilisation of the role across trusts within the ICS. Inconsistencies in scope, expected underpinning education and role activity were identified. Radiographers autonomously reporting in projection radiography were titled advanced practitioners, however are not expected to achieve national educational standards for such roles and are not empowered to work at this level of practice by their employers. It was acknowledged that staffing pressures hinder appropriate role utilisation and reporting capacity.

CONCLUSION

Inconsistent development and utilisation of radiographers in such roles may hamper collaboration and service delivery across a network. Identifying variation and working towards role standardisation could promote cross-organisational working and improve career progression opportunities.

IMPLICATIONS FOR PRACTICE

Scoping the reporting radiographer workforce may assist and guide future imaging service and workforce planning.

Developing architecture of system management in the English NHS: evidence from a qualitative study of three Integrated Care Systems

OBJECTIVE

Integrated Care Systems (ICSs) mark a change in the English National Health Service to more collaborative interorganisational working. We explored how effective the ICS form of collaboration is in achieving its goals by investigating how ICSs were developing, how system partners were balancing organisational and system responsibilities, how partners could be held to account and how local priorities were being reconciled with ICS priorities.

DESIGN

We carried out detailed case studies in three ICSs, each consisting of a system and its partners, using interviews, documentary analysis and meeting observations.

SETTING/PARTICIPANTS

We conducted 64 in-depth, semistructured interviews with director-level representatives of ICS partners and observed eight meetings (three in case study 1, three in case study 2 and two in case study 3).

RESULTS

Collaborative working was welcomed by system members. The agreement of local governance arrangements was ongoing and challenging. System members found it difficult to balance system and individual responsibilities, with concerns that system priorities could run counter to organisational interests. Conflicts of interest were seen as inherent, but the benefits of collaborative decision-making were perceived to outweigh risks. There were multiple examples of work being carried out across systems and 'places' to share resources, change resource allocation and improve partnership working. Some interviewees reported reticence addressing difficult issues collaboratively, and that organisations' statutory accountabilities were allowing a 'retreat' from the confrontation of difficult issues facing systems, such as agreeing action to achieve financial sustainability.

CONCLUSIONS

There remain significant challenges regarding agreeing governance, accountability and decision-making arrangements which are particularly important due to the recent Health and Care Act 2022 which gave ICSs allocative functions for the majority of health resources for local populations. An arbiter who is independent of the ICS may be required to resolve disputes, along with increased support for shaping governance arrangements.

Collaboration over competition? Regulatory reform and inter-organisational relations in the NHS amidst the COVID-19 pandemic: a qualitative study

BACKGROUND

In 2021, during the COVID-19 pandemic, England's Department of Health and Social Care (DHSC) released a White Paper outlining proposed legislative reform of the National Health Service (NHS). Key to the proposals is the shift from relationships between providers based on competition, to cooperation, as the central driver of improved performance and quality. Against this background we explore potential regulatory barriers and enablers to collaboration identified by key NHS stakeholders and assess whether the proposed policy changes are likely to deliver the desired improvement in collaborative relationships, in the context of challenges experienced during the COVID-19 pandemic.

METHODS

We conducted 32 semi-structured interviews with 30 key stakeholders, taking place during the COVID-19 pandemic from Jan 2020 to May 2021. Participants were selected for their expertise regarding collaboration and were recruited purposively. Interviews were conducted online with the use of video conferencing software. The interviews were thematically analysed to identify themes. Proposals contained in the DHSC White Paper helped to structure the thematic analysis, interpretation, and reporting of the results.

RESULTS

Requirements to compete to provide services, regulatory ability to block collaborative arrangements, lack of collaboration between providers and Clinical Commissioning Groups, and current lack of data sharing were found to hamper collaborative efforts. These issues often negatively affected collaborative relations by increasing bureaucracy and prompted leaders to attempt to avoid future collaborations. Other barriers included opaque accountability arrangements, and erosion of trust in regulators. The COVID-19 pandemic was found to foster collaboration between organisations, but some changes mandated by the new legislation may stifle further collaboration.

CONCLUSIONS

Many of the proposed legislative changes in the White Paper would help to remove existing barriers to service integration and collaboration identified by stakeholders. However, the proposed shift in the concentration of power from NHS England to the DHSC may exacerbate historically low levels of trust between providers and regulators. Many of the proposed changes fail to address endemic NHS policy issues such as chronic understaffing. Further dialogue is needed at all levels of the health and social care system to ensure future legislative changes meet the needs of all stakeholders.

What's Needed to Develop Strategic Purchasing in Healthcare? Policy Lessons from a Realist Review

BACKGROUND

In the context of serious concerns over the affordability of healthcare, various authors and international policy bodies advise that strategic purchasing is a key means of improving health system performance. Such advice is typically informed by theories from the economics of organization (EOO). This paper proposes that these theories are insufficient for a full understanding of strategic purchasing in healthcare, because they focus on safeguarding against poor performance and ignore the coordination and adaptation needed to improve performance. We suggest that insights from other, complementary theories are needed.

METHODS

A realist review method was adopted involving 3 steps: first, drawing upon complementary theories from the EOO and inter-organizational relationships (IOR) perspectives, a theoretical interpretation framework was developed to guide the review; second, a purposive search of scholarly databases to find relevant literature addressing healthcare purchasing; and third, qualitative analysis of the selected texts and thematic synthesis of the results focusing on lessons relevant to 3 key policy objectives taken from the international health policy literature. Texts were included if they provided relevant empirical data and met specified standards of rigour and robustness.

RESULTS

A total of 58 texts were included in the final analysis. Lessons for patient empowerment included: the need for clearly defined rights for patients and responsibilities for purchasers, and for these to be enacted through regular patientpurchaser interaction. Lessons for government stewardship included: the need for health strategy to contain specific targets to incentivise purchasers to align with national policy objectives, and for national government actors to build close, trusting relationships with purchasers to facilitate access to local knowledge about needs and priorities. Lessons for provider performance included: provider decision autonomy may drive innovation and efficient resource use, but may also create scope for opportunism, and interdependence likely to be the best power structure to incentivise collaboration needed to drive performance improvement.

CONCLUSION

Using complementary theories suggests a range of general policy lessons for strategic purchasing in healthcare, but further empirical work is needed to explore how far these lessons are a practically useful guide to policy in a variety of healthcare systems, country settings and purchasing process phases.

Towards a framework for enhancing procurement and supply chain management practice in the NHS: lessons for managers and clinicians from a synthesis of the theoretical and empirical literature

Background

This review provides intelligence to NHS managers and clinicians involved in commissioning and procurement of non-pay goods and services. It does this in the light of ongoing pressure for the NHS to save money through a combination of cost cutting, productivity improvements and innovation in service delivery, and in the context of new commissioning structures developing as a result of the Health and Social Care Act 2012 (Great Britain.Health and Social Care Act 2012. Chapter 7. London: The Stationery Office; 2012).

Objectives

We explore the main strands of the literature about procurement and supply chain management (P&SCM); consider the extent to which existing evidence on the experiences of NHS managers and clinicians involved in commissioning and procurement matches these theories; assess how the empirical evidence about different P&SCM practices and techniques in different countries and sectors might contribute to better commissioning and procurement; and map and evaluate different approaches to improving P&SCM practice.

Review method

We use a realist review method, which emphasises the contingent nature of evidence and addresses questions about what works in which settings, for whom, in what circumstances and why. Adopting realist review principles, the research questions and emerging findings were sense-checked and refined with an advisory group of 16 people. An initial key term search was conducted in October 2013 across relevant electronic bibliographic databases. To ensure quality, the bulk of the search focused on peer-reviewed journals, though this criterion was relaxed where appropriate to capture NHS-related evidence. After a number of stages of sifting, quality checking and updating, 879 texts were identified for full review.

Results

Four literatures were identified: organisational buying behaviour; economics of contracting; networks and interorganisational relationships; and integrated supply chain management (SCM). Theories were clustered by their primary explanatory focus on a particular phase in the P&SCM process. Evidence on NHS commissioning and procurement practice was found in terms of each of these phases, although there were also knowledge gaps relating to decision-making roles, processes and criteria at work in commissioning organisations; the impact of power on collaborative interorganisational relationships over time; and the scope to apply integrated SCM thinking and techniques to supply chains delivering physical goods to the NHS. Evidence on P&SCM practices and techniques beyond the NHS was found to be highly fragmented and at times contradictory but, overall, demonstrated that matching management practice appropriately with context is crucial.

Conclusions

We found that the P&SCM process involves multiple contexts, phases and actors. There are also a wide variety of practices that can be used in each phase of the P&SCM process. Thinking about how practice might be improved in the NHS requires an approach that enables the simplification of the complex interplay of factors in the P&SCM process. Portfolio-based approaches, which provide a contingent approach to considering these factors, are recommended. Future work should focus on conflicting preferences in NHS commissioning and procurement and the role of power and politics in conflict resolution; the impact of power on the scope for collaboration in health-care networks; and the scope to apply integrated SCM practices in NHS procurement organisations.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Background

By 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’).

Objectives

To: 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.

Design

Mixed-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.

Results

In 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.

Conclusions

Commissioning 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.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Perspectives on the policy 'black box': a comparative case study of orthopaedics services in England

There has been much recent debate on the impact of competition on the English National Health Service (NHS). However, studies have tended to view competition in isolation and are controversial. This study examines the impact of programme theories associated with the health system reforms, which sought to move from a dominant target-led 'central control' programme theory, to one based on 'market forces', on orthopaedics across six case-study local health economies. It draws on a realistic evaluation approach to open up the policy 'black box' across different contexts using a mixed methods approach: analysis of 152 interviews with key informants and analysis of waiting times and admissions. We find that the urban health economies were more successful in reaching the access targets than the rural health economies, although the gap in performance closed over time. Most interviewees were aware of the policies to increase choice and competition, but their role appeared comparatively weak. Local commissioners' ability to influence demand appeared limited with providers' incentives dominating service delivery. Looking forward, it is clear that the role of competition in the NHS has to be considered alongside, rather than in isolation from, other policy mechanisms.

Implementing market-based reforms in the English NHS: bureaucratic coping strategies and social embeddedness

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.

Evaluating Labour's market reforms, 2002-10

Starting in 2002, the UK Labour government of 1997-2010 introduced a series of changes to the National Health Service (NHS) in England designed to increase individual NHS patient choice of place of elective hospital care and competition among public and private providers of elective hospital services for NHS-funded patients. In 2006, the Department of Health initiated the Health Reform Evaluation Programme (HREP) to assess the impact of the changes. The changes broadly had the effects that proponents had predicted but the effects were mostly modest. Most of the undesirable impacts feared by critics appeared not to have materialized to any discernible extent, at least by early in 2010. Labour's market appeared to have generated stronger incentives for quality and efficiency than its 1990 s predecessor with no obvious detriment to equity of access. However, this high level conclusion conceals a far more nuanced and complex picture of both the process of implementation and the impact of the changes, as the papers in this supplement drawn from the HREP show.