Naomi Chambers

The practice of commissioning healthcare from a private provider: learning from an in-depth case study

BackgroundThe direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services.MethodsA single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the “Livewell project”. 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative.ResultsThe main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory).ConclusionsThe study has surfaced issues around innovation adoption in the healthcare context. The case identifies ‘negotiated order’, managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system.

The role of corporate governance and boards in organisation performance

For more than two decades, successive UK governments have been concerned with modernising the delivery of public services and seeking performance improvements. As part of this drive, corporate governance arrangements across the sector have been reformed and much greater attention has been paid to the training, development and support of those serving on governing bodies and boards. An underlying assumption of these shifts in policy is that improvements in corporate governance arrangements, and in particular the working of boards, will lead to improvements in effectiveness. This chapter examines what evidence there is to support that assumption.

Emergency planning and management in health care: priority research topics

Many major incidents have significant impacts on people’s health, placing additional demands on health-care organisations. The main aim of this paper is to suggest a prioritised agenda for organisational and management research on emergency planning and management relevant to U.K. health care, based on a scoping study. A secondary aim is to enhance knowledge and understanding of health-care emergency planning among the wider research community, by highlighting key issues and perspectives on the subject and presenting a conceptual model. The study findings have much in common with those of previous U.S.-focused scoping reviews, and with a recent U.K.-based review, confirming the relative paucity of U.K.-based research. No individual research topic scored highly on all of the key measures identified, with communities and organisations appearing to differ about which topics are the most important. Four broad research priorities are suggested: the affected public; inter- and intra-organisational collaboration; preparing responders and their organisations; and prioritisation and decision making.

Perspectives on the enablers of e-heath adoption: an international interview study of leading practitioners

Studies examining the application of information technology to the delivery of health-care services often highlight the anticipated benefits. In consequence, the benefits of health-care information technology adoption, often referred to as ‘e-health’, are widely reported yet there is limited empirical evidence as to how such benefits can be realized. Design and implementation guidelines have been considered from a socio-technical perspective and there is support for the successful application of these principles. There are also some global surveys on the topic, but these often report only statistical data and lack richness of content. This study draws on existing literature to examine whether the principles of health-care information technology adoption are currently applied in practice. The paper presents a timely international analysis of the drivers, critical enablers and successful deployment strategies for e-health from the perspective of leading practitioners. The study considers the adoption of e-health in 15 countries. A qualitative research design was used and semistructured interviews were conducted with 38 thought leaders with expertise in health-care information systems and technology. The study presents a comparative analysis of the lessons learned from implementing, integrating and embedding e-health in practice, and presents a four-phase approach from the perspective of practitioners for the accelerated deployment of e-health systems: (i) develop a strategic approach, (ii) engage the workforce, (iii) capitalize on information technology and (iv) partner with the patient/citizen.

Assessing governance theory and practice in health-care organizations: a survey of UK hospices

This paper sets out a theoretical framework for analyzing board governance, and describes an empirical study of corporate governance practices in a subset of non-profit organizations (hospices in the UK). It examines how practices in hospice governance compare with what is known about effective board working. We found that key strengths of hospice boards included a strong focus on the mission and the finances of the organizations, and common weaknesses included a lack of involvement in strategic matters and a lack of confidence, and some nervousness about challenging the organization on the quality of clinical care. Finally, the paper offers suggestions for theoretical development particularly in relation to board governance in non-profit organizations. It develops an engagement theory for boards which comprises a triadic proposition of high challenge, high support and strong grip.

Healthcare reform and leadership

The British National Health Service (NHS) employs over 1.3 million people, and spends about £90 billion a year. Services are delivered through about 300 NHS organisations and 5,200 GP practices. The NHS sees about 1.5 million patients every day. It is a huge enterprise, which dwarfs most other areas of the public sector in scale and complexity, touches the lives of almost every citizen directly or indirectly, and operates under intense public, media and political scrutiny. In any terms, it presents a unique leadership challenge.

Clinical governance and the role of NHS boards: learning lessons from the case of Ian Paterson

Medicine’s enduring professional “club” culture must be eradicated

Use of action learning in a higher education setting to improve the quality of health care

Abstract Health care faces challenges that are only partially addressed by incremental innovations. This paper outlines the potential for action learning to be used to challenge existing paradigms and mindsets. It provides the background and introduction to the concept, and describes the main principles and approach. Limitations in the theoretical conceptualization and research evidence about action learning are explored. Meanwhile, action learning has been used as a learning tool for graduate entry-level health service managers, senior health-care leaders, and students on postgraduate courses. Evaluations of these programmes have unearthed the key characteristics and benefits of effective action learning. The conclusions are that effective action learning is enabled by skilled facilitation, has benefits in embedding double-loop learning and developing personal resilience, and may result in enhanced organizational ambidexterity. Further work is now required to build a stronger conceptual framework and to explore the theory–practice gap around the impact of action learning at the organization level.

Who should serve on health care boards? What should they do and how should they behave? A fresh look at the literature and the evidence

Abstract Public boards of directors face challenges in demonstrating effectiveness and return on investment. Health care boards in particular operate in a high risk service and political environment, where both patient safety and financial sustainability are paramount. The motivation in this article is to make sense of the conflicting and competing theories which explain the purpose of boards, and the sometimes weak and contradictory evidence for effective board practices. The main contributions of the study are, first, the use of a realist approach to understand underlying assumptions behind the main theories for health care boards, and, second, practical suggestions in relation to board composition, focus and behaviours, according to circumstances. Amongst its conclusions, this review indicates that board size should be limited, especially for newer organisations, physicians on boards are associated with better quality of clinical care, and choosing to operate diligently with a focus on strategy and on monitoring, a close grip on the business, and strong support for executives are all important.

Debate: Achieving the benefits of patient-level costing—open book or can't look?

The National Health Service in England is running out of money. With demand increasing all the time, by 2021 the NHS in England will be £30 billion short of what it needs to provide an effective service, free at the point of use (NHS, 2014). Costs by patient are increasingly available through patient-level information and cost systems (PLICS), but little is known about how PLICS are used or their potential. Can PLICS help solve the financial crisis? PLICS are IT systems which combine activity, financial and operational data to cost individual episodes of patient care. As part of a National Institute for Health Research (NIHR) project, a 2013 survey of NHS healthcare providers investigated how PLICS were being used; this was followed up by case studies taking an in-depth view of current and potential uses. The aim was to investigate how PLICS can help in four areas: cost improvement; better resource allocation; understanding clinical variation; and clinical engagement. The emphasis was on achieving gains for the whole NHS economy, not merely the individual trusts where the PLICS are located. This requires an open approach, not shrouding PLICS data from wider view. In 2013, over 120 trusts had implemented a PLICS and a further 86 were implementing or planning to implement (DoH, 2013). The vast majority of these systems are in acute hospital trusts with just a few covering mental health or community services. Almost half of the respondents to the 2013 PLICS survey had been using PLICS data for over two years and most were reporting PLICS data quarterly within their organization. The top six uses given were: