Rod Sheaff

To investigate how far English National Health Service (NHS) Personal Medical Services (PMS) contracts embody a principal-agent relationship between health authorities (HAs) and primary health care providers, especially, but not exclusively, general practices involved in the first wave (1998) of PMS pilot projects; and to consider the implications for relational and classical theories of contract. Content analysis of 71 first-wave PMS contracts. Most PMS contracts reflect current English NHS policy priorities, but few institute mechanisms to ensure that providers realise these objectives. Although PMS contracts have some classical characteristics, relational characteristics are more evident. Some characteristics match neither the classical nor the relational model. First-wave PMS contracts do not appear to embody a strong principal-agent relationship between HAs and primary health care providers. This finding offers little support for the relevance of classical theories of contract,...

Implementing The new NHS and the 1997 NHS (Primary Care) Act will gradually extend cash-limiting into primary health care, especially general practice. UK policy-makers have avoided providing clear, unambivalent direction about how to 'ration' NHS resources. The 'Child B' case became an epitome of public debate about NHS rationing. Among many other decision-making processes which occurred, Cambridge and Huntingdon Health Authority applied an ethical code to this rationing decision. Using new data this paper analyses the rationing criteria NHS managers and clinicians used at local level in the Child B case; and the organisational structures which confronted them with such decisions. Primary Care Groups are likely to confront similar rationing decisions in respect of 'gate-kept' NHS services. However, such rationing processes are not so easily transposed to open-access services such as general practice. NHS rationing decisions, especially in PCGs, will require ...

It is commony claimed that changing the culture of health organisations is a fundamental prerequisite for improving the National Health Service (NHS). Little is currently known about the nature or importance of culture and cultural change in primary care groups and trusts (PCG/Ts) or their constituent general practices. To investigate the importance of culture and cultural change for the implementation of clinical governance in general practice by PCG/Ts, to identify perceived desirable and undesirable cultural attributes of general practice, and to describe potential facilitators and barriers to changing culture. Qualitative: case studies using data derived from semi-structured interviews and review of documentary evidence. Fifty senior non-clinical and clinical managers from 12 purposely sampled PCGs or trusts in England. Senior primary care managers regard culture and cultural change as fundamental aspects of clinical governance. The most important desirable cultural traits were ...

Foundation trusts have boards of directors that are responsible for the day-to-day running of the organisation, planning services and developing strategy. Unlike non-foundation trusts and primary care trusts (PCTs), foundation trusts are not obliged to hold directors' board meetings in public. This article describes the online availability and accessibility of the minutes of such meetings in a number of foundation trusts, non-foundation trusts and PCTs. The implications for transparency in the NHS are also discussed.

... He defined health 'needs' as the states of health or illness that the patient or physician sees are likely to make demands on the medical care system (eg Donabedian 1973). As the problem of scarcity of healthcare resources has become too pressing for the elimination of 'non ...

Epidemiological, demographic and environmental crises, transition to a new political regime and exceptionally severe economic crises were powerful stimuli to health sector reform in Russia. The Russian Federation responded by introducing medical insurance whilst decentralising public administration. Yet despite intense contextual pressures to do so and a new policy climate, Russian hospitals found it difficult to reprofile services and reallocate their resources. A case study analysing governance structures in Sverdlovsk oblast reveals that medical insurance created incentives to reduce costs by reducing bed-days, but if hospitals did so they would lose money under the formulae through which decentralised local government still allocated around three-quarters of hospital income. If instead hospitals tried to increase budgetary income by increasing numbers of bed-days, the insurance system would penalise them. This specific form of policy mess can be called 'governance in gridlock'. The juxtaposition of two overlapping but incompatible sets of governance structures practically immobilised official hospital management systems. It is as one-sided to blame residues of the Soviet system for this gridlock as it is to blame the medical insurance system. Gridlock resulted from the interaction of the two, a problem to which all health system reform is potentially vulnerable.

This qualitative study describes the impact of deploying general practitioners (GPs) as primary care physicians (PCPs) in three Accident and Emergency (A&E) depart-ments in Greater Manchester as part of a Health Action Zone initiative to promote integration of systems of care more ...

... While increased specialisation might inhibit the development of substitutes, these changes also made individual doctors' practice, and medical practice per se, more transparent Page 17. medicine and management in english primary care 643 ...

Health care reforms often include provider diversification, including privatization, to increase competition and thereby health care quality and efficiency. Donabedian's organizational theory implies that the consequences will vary according to the providers' ownership. The aim was to examine how far that theory applies to changes in English NHS primary medical care (general practice) since 1998, and the consequences for patterns of service provision. Framework analysis whose categories and structure reflected Donabedian's theory and its implications, populated with data from a systematic review, administrative sources and press rapportage. Two patterns of provider diversification occurred: 'native' diversification among existing providers and plural provision as providers with different types of ownership were introduced. Native diversification occurred through: extensive recruitment of salaried GPs; extending the range of services provided by general practices; introducing limited liability partnerships; establishing GPs with special clinical interests; and introducing a wider range of services for GPs to refer to. All of these had little apparent effect on competition between general practices. Plural provision involved: increased primary care provision by corporations; introducing GP-owned firms; establishing social enterprises (initially mostly out-of-hours cooperatives); and Primary Care Trusts taking over general practices. Plural provision was on a smaller scale than native diversification and appeared to go into reverse in 2011. Although the available data confirm the implications of Donabedian's theory, there are exceptions. Native diversification and plural provision policies differ in their implications for service development.

Previous studies have suggested that greater focus on clinical matters in NHS commissioner and provider Trust Board meetings might improve the range, quality or cost of clinical care. This study reports the extent of clinical focus in Board meetings in three types of NHS Trust and considers the implications for public accountability. (1) Content analysis of published minutes of Board meetings from 105 randomly selected NHS Trusts in 2008/09. (2) Structured observation of 24 Board meetings in a qualitative sub-sample of eight of the above Trusts in 2008/09. The percentage of clinical items among the items discussed by NHS Trust Boards ranged from 0% to 51%, but did not differ by Trust type. Primary Care Trusts (PCTs) recorded more items than NHS Trusts and NHS Foundation Trusts because of PCTs' dual role as service providers and commissioners. There were significant differences between Trusts' board meetings in the numbers of clinical items concerning service design, clinical outcomes and activity levels. The availability and accessibility of supposedly publicly-available minutes from NHS Foundation Trust Board meetings was sometimes problematic. Observation of meetings revealed a number of dynamics not evident in the minutes. Board meetings were generally chair-led (conducted according to the chair's discretion); collegial; had similar levels and extent of discussion from the non-executive directors, with a focus on current policy initiatives. Boards differed in the extent of public questioning, how they exercised internal governance over the provision and quality of patient care, and the extent of pre-planning before the Board meeting. Published minutes were not always an accurate record of meetings. Findings illuminate important transparency issues which should be given careful consideration in the English NHS.

Providing more information for the public about the range and quality of health services is an important part of improving accountability, quality and public responsiveness. Most sources of information to date have failed to address the information needs of people about their local services. The launch in England in 2002 of a new publication, Guides to Local Health Services, was designed to address this deficiency. We conducted an audit of the first Guides, and surveyed those responsible for their production, in order to examine the Guides' development, content, presentation and dissemination, and to critique the purpose of the initiative. A semi-structured questionnaire survey of those responsible for producing the Guides, and an audit of the Guides produced by Primary Care Trusts (PCTs). Most PCTs complied with central guidance about structure and content, but in meeting multiple requirements the Guides lost their clarity of purpose. The content was dominated by information relating to financial and strategic accountability. In producing the Guides, external consultation was limited, particularly with the public but also with local partnership providers of health and social care. The main issues were the lack of a clear focus for Guide information, the level of central direction, the short production lead times, difficulties with distribution, and the many competing demands being made on PCT resources. Guide content should be clearly focused on information that the public wants. Greater responsibility should be devolved to front line PCT staff to determine content in consultation with local users.