Lorelei Jones

Are NHS foundation trusts able and willing to exercise autonomy? ‘You can take a horse to water…’

Foundation trusts (FTs) have been a central part of the governments National Health Service (NHS) reforms in England since 2004. They illustrate the governments claim to decentralization, by granting greater autonomy to high performing organizations. The number of FTs has grown steadily, reaching 131 in September 2010, over 50% of eligible trusts. Despite this growth, and notwithstanding the fact that organizations which initially became FTs were previously high performing, doubts remain about the implementation of the FT policy. This article examines the implementation of FTs in the NHS and focuses on the nature and exercise of autonomy by FTs. It argues that the ability of FTs to exercise autonomy is in place, but the (relatively limited) extent of implementation may be explained by trusts’ lack of willingness to exercise such autonomy. Such unwillingness may be because of continued centralization, unclear policy and financial regimes, fear of negative impacts on relations with other local organizations, and awareness of greater risk to the FT, among others. Addressing the tension between FTs’ ability and willingness to exercise autonomy will largely explain the extent to which the governments provider side reforms will be implemented.

Framing in policy processes: A case study from hospital planning in the National Health Service in England

This paper reports from an ethnographic study of hospital planning in England undertaken between 2006 and 2009. We explored how a policy to centralise hospital services was espoused in national policy documents, how this shifted over time and how it was translated in practice. We found that policy texts defined hospital planning as a clinical issue and framed decisions to close hospitals or hospital departments as based on the evidence and necessary to ensure safety. We interpreted this framing as a rhetorical strategy for implementing organisational change in the context of community resistance to service closure and a concomitant policy emphasising the importance of public and patient involvement in planning. Although the persuasive power of the framing was limited, a more insidious form of power was identified in the way the framing disguised the political nature of the issue by defining it as a clinical problem. We conclude by discussing how the clinical rationale constrains public participation in decisions about the delivery and organisation of healthcare and restricts the extent to which alternative courses of action can be considered.

Autonomy and improved performance: lessons from an NHS policy reform

Autonomy is currently seen by policy-makers in many countries as a possible mechanism for enhancing public sector performance. The authors examine a service reform (the National Health Service in England) in which more autonomy was given to better performing hospitals. Drawing on data from interviews with senior managers, the research suggests that despite being enmeshed in a politicized culture of regulations and guidance, autonomy is increasingly perceived positively and appears to depend on the extent to which organizations have the incentives and the capacity to respond to increased autonomy. The article presents findings that will be of value to policy-makers in many countries.

Evaluation of the cold weather plan for England: modelling of cost-effectiveness

OBJECTIVE To determine the conditions under which the Cold Weather Plan (CWP) for England is likely to prove cost-effective in order to inform the development of the CWP in the short term before direct data on costs and benefits can be collected. STUDY DESIGN Mathematical modelling study undertaken in the absence of direct epidemiological evidence on the effect of the CWP in reducing cold-related mortality and morbidity, and limited data or on its costs. METHODS The model comprised a simulated temperature time series based on historical data; epidemiologically-derived relationships between temperature, and mortality and morbidity; and information on baseline unit costs of contacts with health care and community care services. Cost-effectiveness was assessed assuming varying levels of protection against cold-related burdens, coverage of the vulnerable population and willingness-to-pay criteria. RESULTS Simulations showed that the CWP is likely to be cost effective under some scenarios at the high end of the willingness to pay threshold used by National Institute for Health and Care Excellence (NICE) in England, but these results are sensitive to assumptions about the extent of implementation of the CWP at local level, and its assumed effectiveness when implemented. The incremental cost-effectiveness ratio varied from £29,754 to £75,875 per Quality Adjusted Life Year (QALY) gained. Conventional cost-effectiveness (<£30,000/QALY) was reached only when effective targeting of at-risk groups was assumed (i.e. need for low coverage (∼5%) of the population for targeted actions) and relatively high assumed effectiveness (>15%) in avoiding deaths and hospital admissions. CONCLUSIONS Although the modelling relied on a large number of assumptions, this type of modelling is useful for understanding whether, and in what circumstances, untested plans are likely to be cost-effective before they are implemented and in the early period of implementation before direct data on cost-effectiveness have accrued. Steps can then be taken to optimize the relevant parameters as far as practicable during the early implementation period.

What does a hospital mean

What we know of hospitals – their location, size, the services they provide and the way they dominate the organizational landscape of the NHS, stems largely from the 1962 Hospital Plan for England and Wales. When the NHS was created in 1948 it inherited an uneven pattern of hospitals made up of a mix of voluntary and local authority provision. The aim of the Hospital Plan was to rationalize and modernize the existing hospital stock, and to better match the geographical distribution of services to apparent need. Problems identified in the Plan included obsolete buildings and a lack of investment in maintenance during Second World War. Moreover, the Emergency Medical Services hospitals built during the war were often of temporary construction and were not located with peace-time needs in mind. The intention was to use the opportunity provided by a rapid increase in capital funding to ‘take a comprehensive view of hospital needs and to formulate a long-term national plan for meeting them’. The Hospital Plan is often portrayed as marking the high water mark of central planning in the NHS. Following the restructuring of the NHS in 1974, responsibility for planning services was delegated to Regional Health Authorities. The hospital plan is also significant in so far as it marks the beginning of arguably the most enduring and intractable issue in the NHS, the political contest over hospital closures. The Plan itself was a collection of regional plans for hospitals based on a centrally dictated norm of 3.3 beds per 1000 population. These regional plans were published alongside an over-arching framework, the centrepiece of which was the ‘District General Hospital’. Comprising 600–800 beds and serving a population of 100,000–150,000, the Distinct General Hospital would provide, with a few exceptions, the full complement of specialist services. A smaller number of specialties that were considered to require a greater catchment area, such as neurosurgery, would only be provided at certain hospitals. The underlying assumption of the Plan was that rationalizing hospitals onto fewer sites would increase efficiency. Although the Plan anticipated that some smaller hospitals would be retained to provide a more limited range of services, such as care for the elderly, it proposed the closure of some 700 hospitals in 10 years. According to the political scientist Rudolf Klein, the publication of the Hospital Plan reflected a nascent ‘ideology of rationality’ in national health care policy. At the time the Plan was published there was an increasing concern with efficiency in public spending; economists were, for the first time, recruited to key posts in the Ministry of Health; and civil servants were beginning to use techniques such as cost-benefit analysis and operational research, a legacy of Second World War military planning. The Plan also represented an alliance between the State and the medical profession. At this time, as now, the medical profession advocated the rationalization of hospitals to concentrate specialist expertise and equipment. In devising norms for the size and distribution of hospitals, the Ministry deferred to the profession. As a consequence, the Plan embodied a professional vision for maximizing the quality of medical care delivered in hospitals. This vision did not take into account other considerations, such as accessibility for patients, their families and staff who needed to travel to and from the hospital at all hours of the day and night. The rationale for the introduction of the District General Hospital was not just economic and clinical but political, reflecting an ideological commitment to the provision of a comprehensive National Health Service and to geographical equity in access to services. In this way, the Hospital Plan might also be seen as representing a rare convergence of economic, medical and political interests. From the outset, there was considerable community resistance to hospital closures, a situation which has

The experience of potentially vulnerable people during cold weather: implications for policy and practice

OBJECTIVES To examine the experience of potentially vulnerable people during cold weather to inform interventions aimed at improving well-being. STUDY DESIGN Qualitative study. METHODS Telephone interviews with 35 individuals who could be considered to be potentially vulnerable during cold weather. Individuals were interviewed on two occasions during the winter of 2012-13, one or two days after a level 3 cold weather alert, as defined by the Cold Weather Plan for England, had been issued. RESULTS Participants were largely unaware of the health risks associated with low temperatures, especially cardiovascular risk. There was a clear distinction between the thermal experience of people in social housing, which was newer, had efficient heating, was well insulated and well-maintained, and owner occupiers living in older, harder to heat homes. Most participants relied on public transport, and many faced arduous journeys to reach basic facilities. Vulnerability to cold was mediated to a significant extent by practical social support from family members. CONCLUSIONS Resources should be targeted at people in hard to heat homes and those that are socially isolated. The repertoire of initiatives aimed at reducing cold-related mortality and morbidity could usefully be augmented by efforts to reduce social isolation and build community resilience.

The art and science of non-evaluation evaluation

This essay considers some limitations of programme theory evaluation in relation to healthcare policies. This approach, which seeks to surface ‘programme theories’ or construct ‘logic models’, is often unable to account for empirical observations of policy implementation in real-world contexts. I argue that this failure stems from insufficient theoretical elaboration of the social, cultural and political dimensions of healthcare policies. Drawing from institutional theory, critical theory and discourse theory, I set out an alternative agenda for policy research. I illustrate the issues with respect to programme theory evaluation with examples from my experience of research on large-scale strategic change in the English NHS.