Do the poor cost much more? The relationship between small area income deprivation and length of stay for elective hip replacement in the English NHS from 2001 to 2008

The Blair/Brown reforms of the English NHS in the early to mid 2000s gave hospitals strong new incentives to reduce waiting times and length of stay for elective surgery. One concern was that these efficiency-oriented reforms might harm equity, by giving hospitals new incentives to select against socio-economically disadvantaged patients who stay longer and cost more to treat. This paper aims to assess the magnitude of these new selection incentives in the test case of hip replacement. Anonymous hospital records are extracted on 274,679 patients admitted to English NHS Hospital Trusts for elective total hip replacement from 2001/2 through 2007/8. The relationship between length of stay and small area income deprivation is modelled allowing for other patient characteristics (age, sex, number and type of diagnoses, procedure type) and hospital effects. After adjusting for these factors, we find that patients from the most deprived tenth of areas stayed just 6% longer than others in 2001/2, falling to 2% by 2007/8. By comparison, patients aged 85 or over stayed 57% longer than others in 2001/2, rising to 71% by 2007/8, and patients with seven or more diagnoses stayed 58% longer than others in 2001/2, rising to 73% by 2007/8. We conclude that the Blair/Brown reforms did not give NHS hospitals strong new incentives to select against socio-economically deprived hip replacement patients.     

On a hiding to nothing? assessing the corporate governance of hospital and health services in New Zealand 1993–1998

In New Zealand the governance of public sector hospital and health services has changed significantly over the past decade. For most of the century hospitals had been funded by central government grants but run by locally elected boards. In 1989 a reforming Labour government restructured health services along managerialist lines, including changing governance structures so that some area health board members were government appointments, with the balance elected by the community. More market oriented reform under a new National government abolished this arrangement and introduced (1993) a corporate approach to the management of hospitals and related services. The hospitals were established as limited liability companies under the Companies Act. This was an explicitly corporate model and, although there was some modification of arrangements following the election of a more politically moderate centre-right coalition government in 1996, the corporate model was largely retained. Although significant changes occurred again after the election of a Labour government in 1999, the corporate governance experience in New Zealand health services is one from which lessons can, nevertheless, be learnt. This paper examines aspects of the performance and process of corporate governance arrangements for public sector health services in New Zealand, 1993-1998.     

Choice vs. voice? PPI policies and the re‐positioning of the state in England and Wales

Context and Thesis  Changing patient and public involvement (PPI) policies in England and Wales are analysed against the background of wider National Health Service (NHS) reforms and regulatory frameworks. We argue that the growing divergence of health policies is accompanied by a re-positioning of the state vis-à-vis PPI, characterized by different mixes of centralized and decentralized regulatory instruments.
Method  Analysis of legislation and official documents, and interviews with policy makers.
Findings  In England, continued hierarchical control is combined with the delegation of responsibilities for the oversight and organization of PPI to external institutions such as the Care Quality Commission and local involvement networks, in support of the government's policy agenda of increasing marketization. In Wales, which has rejected market reforms and economic regulation, decentralization is occurring through the use of mixed regulatory approaches and networks suited to the small-country governance model, and seeks to benefit from the close proximity of central and local actors by creating new forms of engagement while maintaining central steering of service planning. Whereas English PPI policies have emerged in tandem with a pluralistic supply-side market and combine new institutional arrangements for patient 'choice' with other forms of involvement, the Welsh policies focus on 'voice' within a largely publicly-delivered service.
Discussion   While the English reforms draw on theories of economic regulation and the experience of independent regulation in the utilities sector, the Welsh model of local service integration has been more influenced by reforms in local government. Such transfers of governance instruments from other public service sectors to the NHS may be problematic.     

An empirical comparison between the board''s strategic role in nonprofit hospitals and in for-profit industrial firms.

As the health care environment becomes more competitive, nonprofit hospitals are under pressure to adopt for-profit business practices. Based on an extensive field study, this research examines the central issue of organizational governance by comparing the strategic roles of nonprofit hospital boards with for-profit industrial boards. The results show that nonprofit hospital boards are generally more involved in the strategic decision process than their for-profit counterparts. If this governance activity is seen as desirable, hospital boards should exercise caution in emulating for-profit board practices.     

Does Governance Matter? Board Configuration and Performance in Not-for-Profit Hospitals

As performance accountabilities, external oversight, and market competition among not-for-profit (NFP) hospitals have grown, governing boards have been given a more central leadership role. This article examines these boards' effectiveness, particularly how their configuration influenced a range of performance outcomes in NFP community hospitals. Results indicate that hospitals governed by boards using a corporate governance model, versus hospitals governed by philanthropic-style boards, were likely to be more efficient and have more admissions and a larger share of the local market. Occupancy and cash flow were generally unrelated to hospitals' governing board configuration. However, effects of governance configuration were more pronounced in freestanding and public NFP hospitals compared with system-affiliated and private NFP hospitals, respectively.     

An inquiry into good hospital governance: A New Zealand-Czech comparison

Background  

This paper contributes to research in health systems literature by examining the role of health boards in hospital governance. Health care ranks among the largest public sectors in OECD countries. Efficient governance of hospitals requires the responsible and effective use of funds, professional management and competent governing structures. In this study hospital governance practice in two health care systems – Czech Republic and New Zealand – is compared and contrasted. These countries were chosen as both, even though they are geographically distant, have a universal right to 'free' health care provided by the state and each has experienced periods of political change and ensuing economic restructuring. Ongoing change has provided the impetus for policy reform in their public hospital governance systems.     

Getting schooled in governance. N.J. enacts law that will require hospital trustees to receive certified training through class, special leadership curriculum

Those joining hospital boards of trustees in New Jersey will soon have to go to school, according to a new law aimed at boosting their financial and governance savvy. And it could start a trend, as more and more hospitals come under greater scrutiny. "I think trustee leadership is crucial to the survival of the hospitals in New Jersey," said Fred Jacobs, left, state health commissioner.     

Rights of mentally retarded persons in New Zealand and the United States: A comparison

Conclusion With a different form of government, New Zealand’s approach to legal rights for mentally retarded persons remains different from that of the United States. In New Zealand, the political arenas are smaller and primarily involve the parliament, some national agencies, and the local government hospital boards. With a federal system of government, the United States is influenced by more political factors. New Zealand’s more limited political arena accounts for the very prominent role of the New Zealand Society for the Intellectually Handicapped which is partially funded by the national government. However, the legislative approach in New Zealand remains long and arduous. Legislative changes currently being sought include adult guardianship, education rights, separate commitment legislation from the Mental Health Act, and employment rights. The judicial arena has proved a quicker route for establishing rights in the U.S. In actual implementation of rights and protection of individuals, New Zealand may be at an advantage. Its smaller size encourages more humane treatment. In addition, its later implementation allows it to lear from the mistakes of other countries that may have made decisions too quickly. (An example of this is the return to the community movement in the U.S. which has left many mentally handicapped inadequately assisted.)     

Decentralising the NHS: rhetoric, reality and paradox

PURPOSE: The purpose of this research is to examine the issues of decentralisation in the NHS. DESIGN/METHODOLOGY/APPROACH: Evidence was gathered from an empirical study in order to illustrate the effect of policy reform on relationships at both the central and the local level. In this paper issues were examined in the context of two reforms at the heart of the decentralisation agenda in the English NHS: earned autonomy and the introduction of foundation hospitals. FINDINGS: Past and current policy in the NHS reflects elements of both centralisation and decentralisation. The tension created by such opposing forces has an impact not only on inter-organisational partnership working but also on the balance of power within local health economies. ORIGINALITY/VALUE: Attempts to control the NHS exhibit unresolved contradictions and tensions. This research showed that the challenge for policymakers, managers and clinicians is to manage such tensions.     

Emergency transfer from independent hospitals to NHS hospitals: risk, reasons and cost

BACKGROUND: In view of public concern about standards of emergency care in independent hospitals and the impact of transferred patients on NHS facilities we aimed to estimate the number and risk of emergency transfers from independent hospitals to NHS hospitals; to describe the circumstances; and estimate costs to the NHS. METHODS: Patients transferred in three months from 137 independent hospitals were identified from central records systems and local hospital enquiries. Circumstances were described by Directors of Nursing in telephone interviews. Numbers were weighted for whole year activity and non-participating hospitals to estimate total transfers in 1999. Medical Directors of NHS Trusts receiving the patients supplied durations of stay in critical care and other facilities. NHS Reference Costs were applied. RESULTS: There were 158 emergency transfers (plus 105 planned transfers, and 18 as a result of funding problems). Proportionately more emergency transfers were from hospitals lacking intensive care facilities. Patients over 65 years old constituted 61 per cent of transfers but only 25 per cent of all cases. Transfer followed major abdominal surgery in 42 (26 per cent) cases and major orthopaedic surgery in 31 (20 per cent), although these treatments constituted only 2 per cent and 3 per cent of the caseloads. There were an estimated 749 emergency transfers in 1999 (95 per cent confidence interval 640-875), a risk of 1 in 956 (all ages) and 1 in 392 (aged over 65); 729 had been funded privately, of whom two-thirds became NHS patients after transfer, costing Pound Sterling 2.61 million. CONCLUSIONS: The scale of emergency transfer (two per day) and resulting cost to the NHS is small. The risk is reducible if patients and interventions are matched to hospitals' critical care capabilities. Common clinical service guidelines should apply to NHS and independent hospitals.     

Understanding the roles of NHS trust board members

The establishment of NHS trust boards on a business format was a recent innovation resulting from the NHS reforms. In order to realize benefits for patients, it is essential that boards operate effectively. Explores within the framework of corporate governance, the practical implications of board member roles. Drawing on experience of strategy formulation at board level, analyses and clarifies the roles, and presents recommendations to increase board effectiveness.     

Citizen and staff involvement in health service decision-making: have National Health Service foundation trusts in England given stakeholders a louder voice?

OBJECTIVES: National Health Service (NHS) foundation trusts have been created to decentralize the management of NHS provider organizations through the substitution of central government control with local accountability to citizens and employed staff. Our aim was to explore the roles adopted by elected and appointed governors of a first wave NHS foundation trust and the extent to which governors shared power with trust directors and influenced the management of the trust. METHODS: A one-year case study of a single NHS foundation trust (Homerton Hospital in East London) was conducted. Data were collected using face-to-face interviews with a sample of governors and directors, as well as through non-participant observation of public and private meetings of governors and documentary analysis. RESULTS: Governors and directors found the new role of foundation trust governor ambiguous and difficult to define. This lack of clarity impeded the development of the new governance function. Governors perceived that they had made little impact on the decisions of the Trust during the year of study. However, evidence was found of an increased involvement of governors and the public in the activities of the Trust. CONCLUSIONS: Government plans to decentralize accountability of public hospitals to local communities appear problematic, at least in the short term. Unless the effectiveness of the new local governance arrangements is addressed, an accountability 'gap' may emerge as prior mechanisms for public accountability to the centre are dismantled. In these circumstances, decentralization may lead in practice to a loss of public accountability.     

Hospitals in England are failing to follow guidance for tuberculosis infection control - results of a National Survey

Tuberculosis outbreaks can occur in hospitals if adequate infection control is not in place. UK guidelines on the prevention of tuberculosis transmission have recently been published. A national survey of acute NHS Trusts in England was conducted to evaluate whether tuberculosis infection control in hospitals is consistent with the new guidance. There was a 72% response rate (144 NHS Trusts). Sixty percent of Trusts had updated their tuberculosis infection control plans since the new guidance was published. Even trusts with updated plans failed to meet guidance in many areas. Thirty-five percent of Trusts had negative pressure facilities for the isolation of infectious tuberculosis patients. Depending on the risk category of the patient, 45-67% of Trusts met guidelines for isolation of infectious patients. Patients frequently left isolation for non-medical reasons. Only a minority of Trusts complied with guidance for respiratory protection of staff and visitors. These findings suggest that many Trusts remain at risk of outbreaks of tuberculosis and therefore need to re-examine infection control procedures and the availability of isolation facilities.     

Competitive strategy for providers

National Health Service (NHS) Trusts are struggling to determine a long-term strategic direction for their organizations in response to the competitive pressures generated by the NHS reforms. The development of long-term strategic direction and the methods to implement this are presenting real challenges to the Trusts which have inherited service configurations based on bureaucratic planning frameworks rather than service configurations suited to a more competitive environment. Examines the strategic choices available to these organizations; explores the importance of identifying positive strategic choices; and discusses the advantages and disadvantages in the context of the NHS internal market.     

Empowerment or rhetoric? Investigating the role of NHS Foundation Trust governors in the governance of patient safety

Objectives

Involving patients and the public in patient safety is seen as central to health reform internationally. In England, NHS Foundation Trusts are seen as one way to achieve inclusive governance by involving local communities. We analysed these arrangements by studying lay governor involvement in the formal governance structures to improve patient safety.

Methods

Interviews with key informants, observations of meetings and documentary analysis were conducted at a case study site. A national survey was conducted with all acute Foundation Trusts (n = 90), with a response rate of 40% (n = 36). Follow up telephone interviews were conducted with seven of these.

Results

The case-study revealed a complex governance context for patient safety involving board, safety and various sub-committees. Governors were mainly not involved in these formal mechanisms, with participation being seen to pose a conflict of interest with the governors’ role. Findings from the survey showed some involvement of governors in the governance of patient safety.

Conclusions

This study revealed a lack of inclusivity by Foundation Trusts of lay governors in patient safety governance. It suggests action is needed to empower governors to undertake their statutory duties more effectively and particularly through clarification of their role and the provision of targeted training and support to facilitate their involvement in the governance of patient safety.     

The effects of corporate restructuring on hospital policymaking.

Hospital corporate restructuring is the segmentation of assets or functions of the hospital into separate corporations. While these functions are almost always legally separated from the hospital, their impact on hospital policymaking may be far more direct. This study examines the effects of corporate restructuring by community hospitals on the structure, composition, and activity of hospital governing boards. In general, we expect that the policymaking function of the hospital will change to adapt to the multicorporate structure implemented under corporate restructuring, as well as the overlapping boards and diversified business responsibilities of the new corporate entity. Specifically, we hypothesize that the hospital board under corporate restructuring will conform more to the "corporate" model found in the business/industrial sector and less to the "philanthropic" model common to most community hospitals to date. Analysis of survey data from 1,037 hospitals undergoing corporate restructuring from 1979-1985 and a comparison group of 1,883 noncorporately restructured hospitals suggests general support for this hypothesis. Implications for health care governance and research are discussed.     

Decentralisation strategies and provider incentives in healthcare

Introduction

This article examines the incentive effects of delegating operational and financial decision making from central government to local healthcare providers. It addresses the economic consequences of a contemporary policy initiative in the English National Health Service (NHS)–earned autonomy. This policy entails awarding operational autonomy to ‘front-line’ organisations that are assessed to be meeting national performance targets. In doing so, it introduces new types of incentives into the healthcare system, changes the nature of established agency relationships and represents a novel approach to performance management.

Methods

Theoretical elements of a principal-agent model are used to examine the impact of decentralisation in the context of the results of an empirical study that elicited the perceptions of senior hospital managers regarding the incentive effects of earned autonomy. A multi-method approach was adopted. In order to capture the breadth of policy impact, we conducted a national postal questionnaire survey of all Chief Executives in acute-care hospital Trusts in England (n = 173). To provide added depth and richness to our understanding of the impact and incentive effects of earned autonomy at an organisational level, we interviewed senior managers in a purposeful sample of eight acute-care hospital Trusts.

Results

This theoretical framework and our empirical work suggest that some aspects of the earned autonomy as currently implemented in the NHS serve to weaken the potential incentive effect of decentralisation. In particular, the nature of the freedoms is such that many senior managers do not view autonomy as a particularly valuable prize. This suggests that incentives associated with the policy will be insufficiently powerful to motivate providers to deliver better performance. We also found that principal commitment may be a problem in the NHS. Some hospital managers reported that they already enjoyed a large degree of autonomy, regardless of their current performance ratings. We also found evidence that the objectives of providers may differ from those of both the central government and local purchasers. There is, therefore, a risk that granting greater autonomy will allow providers to pursue their own objectives which, whilst not self-serving, may still jeopardise the achievement of strategic goals.

Conclusion

It is apparent that the design and implementation features of decentralising policies such as earned autonomy require careful attention if an optimal balance is to be struck between central oversight and local autonomy in the delivery of healthcare.     

Changes in the structure, composition, and activity of hospital governing boards, 1989-1997: evidence from two national surveys.

Hospital governance arrangements affect institutional policymaking and strategic decisions and can vary by such organizational attributes as ownership type/control, size, and system membership. A comparison of two national surveys shows how hospital governing boards changed in response to organizational and environmental pressures between 1989 and 1997. The magnitude and direction of changes in (1) board structure, composition, and selection; (2) CEO-board relations; and (3) board activity, evaluation, and compensation are examined for the population of hospitals and for different categories of hospitals. The findings suggest that hospital boards are engaging in selective rather than wholesale change to meet the simultaneous demands of a competitive market and traditional institutional orientations to community, the disenfranchised, and philanthropic service. Results also suggest parallel increases in collaboration between boards and CEOs and in board scrutiny of CEOs.     

Changes in the Structure, Composition, and Activity of Hospital Governing Boards, 1989–1997: Evidence from Two National Surveys

Hospital governance arrangements affect institutional policymaking and strategic decisions and can vary by such organizational attributes as ownership type/control, size, and system membership. A comparison of two national surveys shows how hospital governing boards changed in response to organizational and environmental pressures between 1989 and 1997. The magnitude and direction of changes in (1) board structure, composition, and selection; (2) CEO-board relations; and (3) board activity, evaluation, and compensation are examined for the population of hospitals and for different categories of hospitals. The findings suggest that hospital boards are engaging in selective rather than wholesale change to meet the simultaneous demands of a competitive market and traditional institutional orientations to community, the disenfranchised, and philanthropic service. Results also suggest parallel increases in collaboration between boards and CEOs and in board scrutiny of CEOs.     

Hospital governing boards: a study of their effectiveness in relation to organizational performance

This article describes the development and evolution of governing boards and summarizes critical findings from a research study on hospital governing boards. The purpose of the research was to examine factors that measure performance of governing boards and the relationship of governing board effectiveness to the organizational performance of hospitals. Board leaders from 64 nonprofit hospitals across the country were surveyed using the BSAQ tool, which measures board effectiveness in six areas of competency. Board competency scores of this group were compared with those of a previous group, which consisted of more than 300 nonprofit boards, and demonstrated significantly higher scores. A factor analysis conducted to compare the six competency factors between study groups revealed a strong single factor in this study. The factors that measure governing board performance were found to be consolidated into one single factor of collaborative board functioning consistent with emerging governance theory. This may support the concept of the importance of governing boards as collaborative, socially dynamic networks of leaders. The hospital performance was assessed using data from the nationally recognized program, Solucient's 100 Top Hospitals. The results demonstrate that higher performing boards did have better hospital performance in several dimensions, most notably in profitability and lower expenses. Lower expenses were related to higher scores for the BSAQ total score. Hospital profitability was positively correlated with all seven BSAQ scores. A more favorable Solucient ranking was related to hospitals that had a lower BSAQ political score. This was also found in a multiple regression model that predicted a favorable ranking when the BSAQ political score was lower. This may mean that these boards do what needs to be done to maintain excellent performance and do not let politics get in the way of their work. Although governance and its effect on hospital performance is a complex concept to study, this investigation yields findings of interest to leaders in the healthcare field.