Programme approach to managing informed commissioning.

The objective of this paper is to examine possible organizational reasons for why UK NHS commissioners have not adopted programme budgeting and marginal analysis (PBMA). This is despite increasing evidence of discontent with current commissioning and priority-setting processes, increasing research evidence demonstrating the potential of PBMA and support for the principles of PBMA. Two separate semistructured surveys of the views of commissioning decision-makers on the use of PBMA were carried out at Grampian Health Board and Newcastle & North Tyneside Health Authority. Twenty-nine decision-makers were interviewed. Both surveys found common barriers to implementation of PBMA, described by respondents as 'institutional inertia'. These were the reactive rather than proactive environment; the fear of 'unnecessary' explicitness; an aversion to unilateral innovation in the current NHS environment; and the demand for concrete evaluation evidence. It is concluded that these qualitative surveys have small samples and cannot claim to be representative. It may be significant that many issues were common to both surveys carried out separately in organizations. It is unlikely that NHS commissioning will independently adopt techniques such as PBMA, given the current commissioning environment and organizational structures. Implementation strategies and future research on such commissioning innovations may need to focus on institutions as well as the interventions.     

Estimated alcohol consumption in the 1995 National Health Survey: Some methodological issues

OBJECTIVE: This paper critically examines the methodology used to ascertain alcohol consumption in the 1995 Australian Bureau of Statistics National Health Survey (NHS). METHOD: The 1995 NHS was the second in a series of regular, five-yearly population surveys designed to obtain national benchmark information on a range of health-related issues and enable the monitoring of trends over time. The first survey was conducted in 1989-90. In the 1995 NHS, respondents were asked about the quantity of each of seven types of alcohol consumed on up to three days of the week before the interview day. In the 1989-90 NHS, however, respondents were asked about alcohol consumption on each of the seven days before the interview. This paper uses Unit Record Data from the 1989-90 National Health Survey to investigate the methodology used in 1995. RESULTS: It is shown that the estimates of alcohol consumption obtained using the 1995 methodology are highly dependent on the day of the week on which the interviews were conducted. CONCLUSION: It is recommended that the 1995 methodology not be used in future NHS surveys. The 1989-90 methodology of seven-day retrospective diaries would seem a better choice for future National Health Surveys.     

Child Health Surveillance in England and Wales: the good news

Postal surveys were conducted in 1993 among all, or samples of, six groups of providers and managers of pre-school child health surveillance (CHS) in England and Wales. Content analyses were also carried out of strategic policy statements for CHS produced by 54 district health authorities in England and Wales. The surveys aimed to document the views and experiences of CHS providers and managers about the impact of recent changes affecting the structure and operation of CHS, including the publication of Health for All Children , the 1990 Contract for General Practitioners (GPs), the implementation of the National Health Service and Community Care Act 1990 , and the changing roles of community doctors and health visitors. Five positive findings from the surveys are discussed: the impact of the first edition of Health for All Children ; improvements in the development and use of child health information systems; the beneficial effects of the growing involvement of GPs in CHS; the developing understanding of, and commitment to, the principle of clinical audit in CHS; and the growing collaboration between providers in the NHS internal market. A separate paper reports the negative findings from the study.     

Child Health Surveillance in England and Wales: the bad news

Postal surveys were conducted in 1993 among all, or samples of, six groups of providers and managers of pre-school child health surveillance (CHS) in England and Wales. Content analyses were also carried out of strategic policy statements for CHS produced by 54 district health authorities in England and Wales. The surveys aimed to document the views and experiences of CHS providers and managers about the impact of recent changes affecting the structure and operation of CHS, including the publication of Health for All Children , the 1990 Contract for General Practitioners (GPs), the implementation of the National Health Service and Community Care Act 1990 , and the changing roles of community doctors and health visitors. Four adverse findings from the surveys are discussed: fragmentation in the child health service; the unwanted effects of the NHS internal market; the adverse consequences of the changing role of health visitors; and the concerns voiced by the community doctors about the quality of CHS in general practice.     

Status and development of critical incident stress management services in the United Kingdom National Health Service and other emergency services combined: 1993-1996

Surveys conducted amongst members of the Association of NHSOccupational Physicians indicate few changes in the status anddevelopment of Critical Incident Stress Management Services(CISMS) in the United Kingdom National Health Service between1993 and 1996. Limited CISMS are confirmed by the majority ofrespondents in the two surveys with developments having typicallyoccurred within long-established staff care services such ascounselling. In 1996 NHS provision is typically based on theindependent use of own resources. A 1996 comparison of NHS withpooled returns from Ambulance Services, Fire Brigades and SocialServices Departments indicates few variations in status, provisionand levels of expertise in the delivery of CISMS. Other emergencyservices co-operate to a greater extent with each other thandoes the health care sector. Occupational Health Departmentresponders confirm availability of expertise resources to provideCISMS, but low priority status frustrates delivery of CISMS.Survey results indicate the NHS is at risk of not fulfillingits duty to care for staff after major incidents. The establishmentof regional centres of CISMS excellence with local and nationalresponsibilities is advocated.     

Success factors for implementation of the balanced scorecard in a NHS multi-agency setting

Even though the balanced scorecard (BSC) has become a highly popular performance management tool, usage in local public sector National Health Service (NHS) organisations is still rare. This paper conditionally outlines some grounds in supporting such usage. In particular underlying conceptual concerns with the BSC system and its implementation pitfalls require full consideration. This paper then outlines some factors to be taken into account for "successful" BSC implementation in a NHS multi-agency setting. These findings emerged from a series of focus groups that took place with contributors drawn from all the key organisations within the Bradford Health Action Zone. Finally, this paper argues that if key criteria are met, successful implementation of the BSC may then proceed. However, "blind" BSC implementation without consideration of these factors may result in potential "failure".     

Clinical governance is "ACE"--using the EFQM excellence model to support baseline assessment

The introduction of clinical governance in the "new NHS" means that National Health Service (NHS) organisations are now accountable for the quality of the services they provide to their local communities. As part of the implementation of clinical governance in the NHS, Trusts and health authorities had to complete a baseline assessment of their capability and capacity by September 1999. Describes one Trust's approach to developing and implementing its baseline assessment tool, based upon its existing use of the European Foundation for Quality Management (EFQM) Excellence Model. An initial review of the process suggests that the model provides an adaptable framework for the development of a comprehensive and practical assessment tool and that self-assessment ensures ownership of action plans at service level.     

Setting an example: food and health policy within the National Health Service

The factors involved in implementing Food and Health Policieswithin the United Kingdom's National Health Service (NHS) havebeen examined with special reference to three District HealthAuthorities which have pioneered work in this area. A pointof view is presented of the standardized approaches developedfor education programmes aimed at stimulating interest and increasingthe knowledge of consumers and health educators, and of thepractical dietary modifications required in adapting recipesof traditional dishes and in decreasing or replacing unsuitablemenu choices. The level of commitment and practical limitationsof the catering departments can be identified as the most frequentrate-determining element in policy implementation. However,the necessary changes can often be presented to catering departmentsas interesting challenges with possible financial advantages.The structure of the NHS offers particular opportunities forestablishing and evaluating Food and Health Policy: staff frommany disciplines can become involved in a programme of preventivemedicine which is also likely to lead to improvements in patient-carenetworks. Organization at district level, however, has tendedto result in duplication of effort, errors and costs. Althoughstudies to evaluate Food and Health Policies have been designedin most districts, to date these have tended to concentrateon catering aspects. Full assessment of the policies will onlybe possible if standardised methods of evaluation are integratedinto all stages of implementation programmes.     

Benchmarking clinical photography services in the NHS

Benchmarking is used in services across the National Health Service (NHS) using various benchmarking programs. Clinical photography services do not have a program in place and services have to rely on ad hoc surveys of other services. A trial benchmarking exercise was undertaken with 13 services in NHS Trusts. This highlights valuable data and comparisons that can be used to benchmark and improve services throughout the profession.     

Empowerment: the right medicine for improving employee commitment and morale in the NHS?

States that in recent years, empowerment of National Health Service (NHS) Trust employees has been given substantial political and managerial support. Examines the extent to which the commitment and morale of staff in two NHS Trust hospitals has altered following the introduction of a raft of techniques under the empowerment label. The researchers interviewed substantial numbers of staff with managerial responsibilities, personnel specialists and conducted written surveys seeking employee opinion. Reports the findings, which confirm that, under empowerment, the work of both managers and staff has become more intensive, but managers claim that their commitment has risen, while for non-managerial employees, severe problems of commitment to the Trust, declining morale and high stress were exposed. Identifies reasons for these difficulties which were: the salience of budgetary and operational priorities; lack of training; resistance to the implementation of empowerment; and recognition that little real authority was being devolved to employees. Concludes that the limited effects attributable to empowerment could be explained by its association with harder-edged manpower policies introduced to meet financial and competitive pressures. Under favourable contextual conditions, empowerment may exert more positive effects.     

NHS Regional Librarians Group evidence to the Functions and Manpower Review 1993-94. Management of library services in the proposed new structure

The mission of the library and information service is to ensure that the knowledge base of health care is available and accessible to all providers, purchasers and consumers, and to promote and encourage its effective use. Access should be free at the point of use. Library services should be a national and regional responsibility. The close association with Postgraduate and Continuing Medical and Dental Education should continue. Clear terms of reference for library and information services should guarantee access to these services for all National Health Service (NHS) staff. There should be greater emphasis on quality aspects of information. Information Management and Technology (IM & T) strategy should take full account of the needs of library and information services so that the NHS investment in information networks can be fully realized. Good practice in library and information services should be identified, promoted and disseminated. National Health Service Management Executive (NHS-ME) initiatives which affect the library services of the NHS should be co-ordinated. A working party of users and librarians, working within the Functions and Manpower Review implementation process, should define a structure for the management and provision of NHS library services which gives the most value for money.     

Is the British National Health Service equitable? The evidence on socioeconomic differences in utilization

Is the British National Health Service (NHS) equitable? This paper considers one part of the answer to this: the utilization of the NHS by different socioeconomic groups (SEGs). It reviews recent evidence from studies on NHS utilization as a whole based on household surveys (macro-studies) and from studies of the utilization of particular services in particular areas (micro-studies). The principal conclusion from the majority of these studies is that, while the distribution of use of general practitioners (GPs) is broadly equitable, that for specialist treatment is pro-rich. Recent micro-studies of cardiac surgery, elective surgery, cancer care, preventive care and chronic care support the findings of an earlier review that use of services was higher relative to need among higher SEGs.     

Local authority scrutiny of health: making the views of the community count?

Objective To look at the preparations being made for the introduction of scrutiny of local health services by social service local authorities. Design A baseline postal survey carried out in late 2002 of all social service local authorities in England. Setting Against a backdrop of changing structures and policy, both within local government and the National Health Service (NHS) in England and before the official introduction of health scrutiny in January 2003. Survey from the local authority perspective. Results Progress is being made in the implementation of this new policy, and many local authorities have already carried out pilot scrutiny exercises of local health provision. The survey highlights the different approaches authorities are taking to initiate implementation of health scrutiny and the importance of support, in terms of resources, guidance and training, for overview and scrutiny to be successful. Discussion and Conclusions Further evaluation of the implementation of health scrutiny is required to examine the impact on local governance of the NHS and partnership working.     

Connecting for health. Slow on the uptake

Trusts must increase their IT spending to implement NHS Connecting for Health. Money for implementation falls outside the IT programme. IT is competing against other priorities, but early investors will reap the benefits.     

Clarifying the scope of Italian NHS coverage. Is it feasible? Is it desirable?

The reduction in National Health Service (NHS) expenditure as a share of total health care expenditure, the fragmentation of the NHS into 21 regional systems and the implementation of a 'quasi-market' on the provider side of the system has pressed the government to define and specify, in detail, the set of services that are to be guaranteed by the public sector. To understand whether rationing can be more rational and explicit in the Italian NHS, the following are analysed: (i) the new positive list of drugs, as a major example of limiting and making more rational NHS pharmaceutical coverage; (ii) the Di Bella case, as an example of the difficulties of rational policy-making on sensitive issues; (iii) what Italian people think about health care rationing and priority setting (using the 1998 Eurobarometer Survey);( iv) the criteria defining the set of 'essential services' to be guaranteed to all Italian citizens, which are contained in the recently released National Health Plan. The 'revolution' that has taken place in the pharmaceutical sector shows it is feasible to limit, in an explicit and rational way, the extent of NHS coverage. However, the re-classification of the positive list should be regarded as an exceptional event in the history of Italian social policy. The 'Di Bella' case, on the contrary, shows that limiting NHS coverage can be very unpopular, and that the Italian cultural and social context can be unfavourable for the implementation of hard choices. Public attitude toward rationing seems to confirm that Italians are not familiar with rationing issues. Thus, it is very difficult to predict whether the national government will really go ahead with the implementation of a 'list of essential services' and whether this attempt will be successful. Rationing and priority setting should be discussed in the context of a general debate concerning the future of the Italian NHS.     

Outcomes,Outcomes Research and Disease Management

The UK National Health Service (NHS) is in the process of further reforms aimed at restoring a national focus to its activities and also at enhancing the quality of the service it provides. Key features are: (i) the formation of primary care groups to replace general practitioner (GP) fundholders, holding a single devolved budget for the majority of NHS services; (ii) a move towards defining outcome and performance indicators for the NHS; (iii) the establishment of new bodies to develop and monitor the implementation of clinical guidelines; (iv) the evaluation of new technologies including pharmaceuticals; and (v) a new framework termed ‘clinical governance’ for the long term maintenance of quality.This approach to quality and outcomes may start to move the NHS away from its focus on processes, but in the short term at least, the ability to make this change is limited by the performance indicators available. Many of these indicators are process markers rather than true outcomes, but given the poor outcomes data currently collected by the NHS, it may be all that is possible for the moment.The commitment to better quality in the NHS may make underfunding of the NHS more obvious and lead to further political difficulties for the government. Disease management systems which have in-built markers of their quality, both in terms of the service provided and its outcomes, may look increasingly attractive to the NHS. Outcomes research in the NHS will remain clinically focused for the moment but, with the explicit consideration of cost effectiveness underlying clinical guidelines in the future, a gradual move to the US type of outcomes research is possible in the future.     

Healthcare access and mobility between the UK and other European Union states: an 'implementation surplus'

European Union (EU) policy on mobility requires ensuring healthcare access for EU residents who travel between EU states. This case-study investigates how this policy has been implemented in respect of EU visitors to the UK. EU visitors to the UK have similar access to 'immediately needed' National Health Service (NHS) healthcare to UK residents. For non-urgent healthcare, the NHS has official systems to discourage 'medical tourism' and divert such patients to the private sector or to reclaim the costs of NHS hospital treatment for EU visitors. Yet these official systems contrast with the flexibility and liberality of actual NHS practice towards EU visitors. Research on health policy implementation mostly examines reasons for 'implementation failure'. However, the present study indicates a health policy being implemented more fully than policy-makers may have anticipated. In the case of healthcare access for EU visitors to the UK, an implementation surplus is evident rather than an implementation deficit.     

Loss of British-trained doctors from the medical workforce in Great Britain

OBJECTIVE: To summarize trends over time in the percentage of British medical graduates who subsequently practise in Great Britain in the National Health Service (NHS), in Great Britain outside the NHS, outside Great Britain, or do not practise medicine. DESIGN: Questionnaire-based postal surveys and government employment records. SETTING: Great Britain. SUBJECTS: All British medical graduates of 1974, 1977, 1983, 1988, and 1993. MAIN OUTCOME MEASURES: Type and location of employment at successive years after graduation. RESULTS: Differences in career destination between cohorts were generally small. Combining data from all cohorts studied, 85% of doctors were working in the NHS 2 years after graduation, 82% after 5 and 10 years, 81% after 15 years, and 77% after 20 years. Part-time working was much higher among women than among men. Allowing for loss and part-time working, the whole-time equivalent available to the NHS at 15 years after graduation was 60% of women and 80% of men. More men than women worked in medicine outside the NHS in Britain and abroad. Loss from medicine altogether was small, and higher among women. CONCLUSIONS: Medical workforce planning in Great Britain should assume that 15-20% of home-trained doctors will not be working in the NHS within a few years of graduation. Comparing cohorts at the same career stage showed no evidence of increased loss from the NHS in recent times. Although a higher percentage of women than men were not working in medicine at all, recent trends suggest that this percentage is falling.     

Assessment and improvement of the Italian healthcare system: first evidence from a pilot national performance evaluation system

The Italian National Health System (NHS), established in 1978, follows a model similar to the Beveridge model developed by the British NHS (Beveridge 1942; Musgrove 2000). Like the British NHS, healthcare coverage for the Italian population is provided and financed by the government through taxes. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, in Italy the strong policy of decentralization, which has been taking place since the early 1990s, has gradually shifted powers from the state to the 21 Italian regions. Consequently, the state now retains limited supervisory control and continues to have overall responsibility for the NHS in order to ensure uniform and essential levels of health services across the country. In this context, it has become essential, both for the ministry and for regions, to adopt a common performance evaluation system (PES). This article reports the definition, implementation, and first evidences of a pilot PES at a national level. It shows how this PES can be viewed as a strategic tool supporting the Ministry of Health (MoH) in ensuring uniform levels of care for the population and assisting regional managers to evaluate performance in benchmarking. Finally, lessons for other health systems, based on the Italian experience, are provided.     

Is this satisfaction survey satisfactory? Some points to consider in their planning and assessment

Measuring patient satisfaction is one of the commonest evaluation activities in the NHS. The main aim of the article is to highlight some of the most important aspects of planning, undertaking and critically appraising satisfaction surveys. Key areas considered include: survey aims; definition of concerns; nature of survey populations; methods; interpretation of results; and outcomes and implementation.