Judith Smith

Primary care trusts

Premature reorganisation, with mergers, may be harmful

From quasi-market to market in the National Health Service in England: what does this mean for the purchasing of health services?

The purchasing function was first developed within the British National Health Service as part of a quasi-market introduced by a Conservative government in 1990 and retained by the Labour government on coming to power in 1997. Since 2002 further reforms in England have begun to transform the quasi-market into a ‘real’ market with greater diversity of supplier, including from the private sector, a payment regime designed to reward additional hospital activity and new rights for patients to choose their provider. Evidence from the quasi-market era suggests that the purchasing function made little significant impact on services for patients or shifts in the pattern of hospital provision. The new market reforms, in theory, provide an opportunity to overcome prior weaknesses in the purchasing function. As this market develops, we suggest that the purchasers should develop three new sets of skills and activities if they are to be effective: the identification of need and shaping of demand; shaping the structure of supply; and holding the market to account.

Divisions of general practice in Australia: how do they measure up in the international context?

BackgroundSince the late 1980s, there has been evidence of an international trend towards more organised primary care. This has taken a number of forms including the emergence of primary care organisations. Underpinning such developments is an inherent belief in evidence that suggests that well-developed primary care is associated with improved health outcomes and greater cost-effectiveness within health systems. In Australia, primary care organisations have emerged as divisions of general practice. These are professionally-led, regionally-based, and largely government-funded voluntary associations of general practitioners that seek to co-ordinate local primary care services, and improve the quality of care and health outcomes for local communities.DiscussionIn this paper, we examine and debate the development of divisions in the international context, using six roles of primary care organisations outlined in published research. The six roles that are used as the basis for the critique are the ability of primary care organisations to: improve health outcomes; manage demand and control costs; engage primary care physicians; enable greater integration of health services; develop more accessible services in community and primary care settings; and enable greater scrutiny and assurance of quality of primary care services.SummaryWe conclude that there has been an evolutionary approach to divisions development and they now appear embedded as geographically-based planning and development organisations within the Australian primary health care system. The Australian Government has to date been cautious in its approach to intervention in divisions direction and performance. However, options for the next phase include: making greater use of contracts between government and divisions; introducing and extending proposed national quality targets for divisions, linked with financial or other incentives for performance; government sub-contracting with state-based organisations to act as purchasers of care; pursuing a fund-holding approach within divisions; and developing divisions as a form of health maintenance organisation. The challenge for the Australian Government, should it wish to see divisions role expand, is to find mechanisms to enable this without compromising the relatively strong GP engagement that increasingly distinguishes divisions of general practice within the international experience of primary care organisations.

Big Business: The Corporatization of Primary Care in the UK and the USA

The corporatization of primary care in the USA and the UK over recent years has transformed the way that these services are managed and delivered. Traditional approaches based around small practices of doctors and their teams as the primary organizational unit have been largely overtaken by new models in which doctors, nurses and other primary care professionals work within much larger organizations. This article explores the experience in the USA and the UK of seeking to organize primary care more corporately, and suggests that a tightly managed organizational model does not work well in primary care. Looser, network-based models are needed in which some of the benefits of corporatization can be achieved while the traditional small-organization virtues of primary care can continue to thrive.

Developments: Developing Primary Care Groups in the New NHS: Towards Diversity or Uniformity?

This article examines how the Governments ‘third way’ is being implemented in relation to the involvement of primary care professionals in the commissioning of health services. Prior to 1997, the single preferred model of GP fundholding evolved into a diversity of approaches to commissioning and these approaches became increasingly collaborative rather than competitive. From this starting point, the authors examine the key assumptions underlying the present single model of the primary care group (PCG) as the commissioning body for the ‘New NHS’. They suggest that PCGs will also evolve into a diversity of models, but there will be tensions arising over the greater emphasis on central direction and performance management.

Developing sustainable collaboration: learning from theory and practice

The governments health policy now demands effective collaboration between organizations, between commissioners and providers of care and between health and local authorities, the voluntary sector and the public. Making collaboration work at operational and strategic levels is a significant management challenge. This paper draws on experience and observation of two forms of strategic collaborative venture that have been established with the ultimate purpose of improving the publics health. The first concerned itself with mechanisms for commissioning health and social care services on a locality basis, while the other venture was concerned with the promotion of physical activity across a health authority district. Using a framework which identifies the forms of value attributable to collaborative working, the analysis evaluates the processes of development of the two initiatives and identifies some key lessons for developing sustainable collaborative ventures. The framework used is proposed as being appropriate for the formative evaluation of future collaborative initiatives.

Tackling the NHS’s unprecedented deficit and securing reform

The new government’s response has so far largely missed the point

Hospital culture and clinical performance: where next?

Contemporary health policies frequently invoke notions of ‘culture’ and ‘cultural change’ as levers for achieving performance improvement and good-quality healthcare.1 But it has remained unclear whether talk of culture is largely empty rhetoric or whether framing healthcare organisations in ‘cultural’ terms offers useful insights that might improve organisational processes and outcomes of care. When considering the role of organisational culture in facilitating high-quality care and improved outcomes, a first important step is to explain what is meant by organisational culture, and then consider the evidence that organisational culture can be purposively managed and form part of efforts to improve quality and clinical performance in healthcare delivery organisations.nnA recent systematic review found a consistent association between positive organisational and workplace cultures and beneficial clinical outcomes, including reduced mortality rates across a variety of health settings.2 Most ‘included’ studies in the review consisted of observational and cross-sectional designs, and only four were intervention studies. It is therefore very timely that two linked articles in this issue of the journal draw on an interventionist study design and present fresh empirical evidence for a culture–clinical outcome relationship in hospital settings.nnLeslie Curry and colleagues3 conducted a 2-year, mixed-methods, prospective interventionist study (Leadership Saves Lives) designed to promote positive changes in organisational culture in 10 hospitals in the USA. Quantitative changes in organisational culture were measured using a validated 31-item survey instrument (reflecting five subscales of domains …

Comprehensive spending review and the NHS

Financial crisis is deferred but not averted

Managed Care: A Framework for Resource Allocation in the NHS

In this article, resource allocation in the NHS is examined from the perspective of US managed care. A distinction is drawn between the roles of payers, commissioners and providers of health care, and the emergence of UK-style ‘health maintenance organisations’ (HMOs) is identified. The key features of US managed care are applied to case study pre-Primary Care Group (PCG) primary care organisations, and the importance of the contracting relationship and of patient choice emerge as issues for resource allocation. This is followed by a checklist of questions for resource allocation in the emerging PCGs and Primary Care Trusts — the true UK ‘HMOs’. The vital role of the Health Authority as system regulator is underlined.