The UK National Health Service approach to the economic crisis

Journal of the Royal Society of Medicine (Impact Factor: 2.12). 04/2010; 103(4):123-4. DOI: 10.1258/jrsm.2010.100061
Source: PubMed

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    • "From the commissioners’ point of view, and to a lesser extent providers’, much of the motivation to bring about change came neither from financial concerns nor serving patients’ interests, but from national policy. Local commissioners were working to national guidance in terms of what they should be trying to achieve in long term conditions management [17,18] and wished to be seen to be performing well in these terms: delaying the onset and progression of long term conditions; finding cost savings and efficiencies; and reducing the need for unscheduled acute admissions. In addition, for each of the three long terms conditions, the Department of Health had produced a National Service Framework or Strategy [19-21], supported by NICE guidelines and by more detailed models of good practice. "
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    ABSTRACT: Background: Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market. Methods: We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents. Results: In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services.In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach. Conclusions: Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.
    Full-text · Article · May 2013 · BMC Health Services Research
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    ABSTRACT: Improving performance is an imperative for most healthcare systems in industrialised countries. This article considers one such system, the UK's National Health Service (NHS). Recent NHS reforms and strategies have advocated improved healthcare productivity as a fundamental objective of policy and professional work. This article explores the construction of productivity in contemporary NHS discourse, analysing it via the Foucauldian concept of governmentality. In this manner it is possible to investigate claims that the commodification of health work constitutes a threat to autonomy, and counter that with an alternative view from a perspective of neoliberal self-governance. Contemporary policy documents pertaining to NHS productivity were analysed using discourse analysis to examine the way in which productivity was framed and how responsibility for inefficient resource use, and possible solutions, were constructed. Data reveals the notion of productivity as problematic, with professionals as key protagonists. A common narrative identifies traditional NHS command/control principles as having failed to engage professionals or having been actively obstructed by them. In contrast, new productivity narratives are framed as direct appeals to professionalism. These new narratives do not support deprofessionalisation, but rather reconstruct responsibilities, what might be called ‘new professionalism’, in which productivity is identified as an individualised professional duty.
    No preview · Article · Oct 2013 · Sociology of Health & Illness