Call My Bluff: Multiple Interpretations of an Organizational Process

This paper attempts to illustrate the value of interpreting organizational processes from a variety of perspectives. It demonstrates that this approach reflects the natural richness of organization and avoids the rather blinkered search for single-paradigm explanations. It does not seek to offer the answer, but rather some possible insights. By combining both actor and researcher frames, it sheds light upon a particular process of social interaction within an organization. Both the context, an NHS trust hospital, and the content, a significant change scenario, brings richness and relevance to the debate.
The paper outlines the macro and micro context before focusing on the interpretative methodological approach. The research involved collecting and analysing over thirty hours of taped, semi-structured interview discourse with senior and middle management and some junior staff. After describing the change initiative, an attempt at multi-skilling and the response of recipient actors to the proposals, the paper outlines three readings which seek to explain the events that occurred. The reader is invited to play the game 'Call my Bluff' and to choose the scenario that represents the most plausible explanation. The three interpretative frames employed are a managerial, a cultural and a political perspective. The paper concludes by raising some important issues in research, organizational change and the NHS.     

Measuring the health patterns of the ‘mixed/multiple’ ethnic group in Britain: data quality problems,reporting issues,and implications for policy

The ‘mixed’ group, officially recognised in the 2001 Census, is one of the most rapidly growing ethnic groups in Britain. Although ‘mixed’ categorisation was added to ethnic coding in NHS datasets, our knowledge of health patterns for this population is meagre. Data quality problems remain a key obstacle, including poor reproducibility of the data and constraints on reporting due to sparse data bias. The consequent minimal and indicative evidence base has focused mainly on risky health behaviours, mental health and generic measures of self-rated health, as it has in the U.S.A. and Canada. There is negligible information on the main underlying causes of death, such as neoplasms, heart disease and stroke. Consideration should be given to pooling data across multiple years of health and general purpose surveys to enable reporting for the four ‘mixed’ categories and adjustment for mediating factors and relevant confounders, such as measures of socio-economic status.     

Querulous Citizens: Welfare Knowledge and the Limits to Welfare Reform

Governments face pressures to improve services and (at the same time) to contain taxes and to ensure that their decisions are accountable to increasingly well‐informed and challenging citizens. The dilemma of “squaring the welfare circle” confronts New Labour in a particularly acute form, since the party has set ambitious targets for improvements in the NHS, education and elsewhere, and is also committed to economic prudence and transparency. This article uses new data from a major national survey to investigate knowledge and beliefs in the main policy areas. It shows that most people are generally strikingly well‐informed in some areas and ill‐informed in others. A government which wishes to pursue a progressive direction in redistribution, increasing taxation of the better‐off, or expanding provision for those on low incomes, faces real difficulties because many people hold inaccurate beliefs about policy impact and the policy context in these areas. However, NHS costs are more accurately perceived across the population, and the proposed expansion is likely to create less controversy. Current high‐profile policies appear to follow the contours of public knowledge reasonably accurately, but further policy development will require positive efforts to lead debates and improve public knowledge.     

英国NHS改革对我国的启示

回望近30年的改革历程,以内部市场导向的NHS改革在提升医疗服务效率、增强医疗机构回应性以及控制医疗费用增长等方面取得了较好的成效.本文旨在考察和分析英国NHS改革的现实动因与路径选择,以期获得对英国NHS改革的理性认识及其对我国医疗卫生体制改革的有益启示.     

Garbage‐can Policy‐making Meets Neo‐liberal Ideology: Twenty Five Years of Redundant Reform of the English National Health Service

The garbage‐can theory of decision‐making (Cohen et al. 1972), has been adapted into a perspective on policy‐making, with adaptations of the approach placing notable emphasis upon the health sector (Kingdon 2006; Paton 2006). This article creates an adapted ‘garbage‐can’ framework to help explain each stage of the reform of the English National Health Service (NHS) over the last 25 years. The emergence of the key idea and resultant policy at each stage of reform of the English NHS has been arational and indeed sometimes irrational. Policy has reflected advocacy by policy‐salesmen (Kingdon 2002), proffering ‘solutions’ to ill‐defined problems and answers to unasked questions, and politicians' short‐termist responses at each decision‐point. Yet the garbage‐can alone is not enough: if arationality rules in policy‐making day to day, this does not mean that there is not an overall ideological context, trend or bias in reform. The article also posits that ‘market reform’ has derived from the ideological hegemony of a naive anti‐statism (hostility to a misleadingly defined and often mythological ‘centralist state’) in public services and enthusiasm for market competition rather than any evidence‐based application of pro‐market ideas to health policy. A question arises: how are these two approaches (short‐term arationality and longer‐term ideological bias) combined in explanation of how policy over time is biased in a particular direction while seemingly arbitrary and directionless at each messy decision‐point. The article attempts to combine the insights of a garbage‐can approach with wider explanations of ideological hegemony.     

The Civilizing Process of Trust: Developing Quality Mechanisms which are Local,Professional‐led and thus Legitimate

‘Quality’ and ‘performance’ have become defining concepts for policymakers and health‐care systems alike. Yet whilst these principles are of fundamental importance, their practical implementation and assurance are far from straightforward. This commentary analyses the difficulties faced in enhancing quality and performance in the English NHS. Many recent initiatives have been driven through incentives and external auditing of the professionals providing health care on the frontline. Drawing on recent literature and research findings, we argue that this checking‐based ‘audit culture’ is fundamentally flawed in driving quality and performance. Many targets and measures are too crude to reflect important aspects affecting patient outcomes and therefore these frameworks lack legitimacy amongst professionals. An alternative, trust‐based model is proposed – one more capable of acknowledging the meaning, complexity and specificities inherent to professional work. Quality mechanisms developed locally by professionals are able to produce the legitimacy crucial for their effectiveness. It is argued that the normative obligation of approaches based on conditional trust is a more compelling incentive towards good practice than targets and sanctions. This governance by ‘the social’ is able to motivate a more holistically enlightened and consistent reflexivity towards practice, though it is only able to flourish in the absence of purposive‐rational systems.     

Factors Influencing Uptake and Use of a New Health Information App for Young People

Abstract

When young people need health information they are increasingly likely to use online sources and health apps (applications). Yet, these are not necessarily well-designed, reliable or appropriate, and research has primarily focused on adult use. Our study is the first to use qualitative mixed methods (focus groups and interviews) to apply the Technology Acceptance Model (TAM) to understand 26 young people’s uptake and use of a new, clinically-approved health app (application) for 16–25?year olds. We found that perceived usefulness, perceived ease-of-use, social influences and trust, all differently impacted children and young people health-app acceptance and effectiveness. Implications for future research and young-person health-app development are discussed.     

Logistics and procurement outsourcing in the healthcare sector: A comparative analysis

As outsourcing ventures become more complex, opportunities for synergies and efficiencies increase, but also create longer and more fragmented supply chains which could have disastrous consequences, particularly in a healthcare context. This study investigates the implications of outsourcing on healthcare supply chains by comparing two alternatives: outsourcing from public-to-private and outsourcing from public-to-public. A conceptual framework, adapted from previous literature, has been employed to provide a comprehensive overview of the phenomenon and consider the implications of logistics and procurement outsourcing on the healthcare supply chain structure and performance. The study presents a European cross-country comparison, analysing both the National Health Service (NHS) outsourcing in England (public-to-private outsourcing) and the Regional Health Service (RHS) outsourcing in the Tuscany region (Italy) (public-to-public outsourcing). Specificities and commonalities of the two outsourcing experiences provide suggestions for managers and policy-makers and enhance the current knowledge of outsourcing in the public healthcare sector.     

An evaluation of the effects of a National Health Service Trust merger on the learning and development of staff

Although mergers are increasingly common amongst National Health Trusts in the UK there is limited research on how National Health Service (NHS) mergers influence the learning and development of staff. This paper bridges the gap in the literature, through a case-study of a recent NHS Trust merger. It gives an account of the delivery of human resource development (HRD) post merger as seen through the eyes of staff from across the merged organization. The data were obtained from 21 unstructured interviews, nine group discussions, two focus group discussions and a form of micro-ethnography. In addition, quantitative data were used for triangulation purposes. Findings show that power differentials, cultural clashes and unequal access to training and development amongst staff have resulted in hostility towards the new organization. However, the strong management structures for professional members of staff have facilitated knowledge exchange across boundaries in the merged organization. The paper concludes by suggesting that without senior managers dealing with cultural issues and inequitable development opportunities, a number of unintended consequences of the merger are likely to occur.     

New Models of Contracting in the Public Sector: A Review of Alliance Contracting,Prime Contracting and Outcome‐based Contracting Literature

The coordination of public services is an enduring challenge and an important policy priority. One way to achieve collaboration across organizational boundaries, which is being considered in public services such as the English National Health Service (NHS), is through the adoption of alliance contracting, prime provider contracting and outcome‐based contracting. This article reviews the cross‐sectoral literature concerning the characteristics of these new contractual models, how they function, their impact, and their relation to public sector governance objectives. These new contractual forms are characterized as models which, in line with the New Public Management (NPM)/post‐NPM agenda, seek to incentivize providers through the transfer of risk from the commissioners to the providers of services. Key findings are that the models are likely to incur high transaction costs relating to the negotiation and specification of outcomes and rely heavily on the relational aspects of contracting. There is also found to be a lack of convincing cross‐sectoral evidence of the impact of the models, particularly in relation to improving coordination across organizations. The article questions the reconciliation of the use of these new contractual models in settings such as the English NHS with the requirements of public sector governance for transparency and accountability. The models serve to highlight the problems inherent in the NPM/post‐NPM agenda of the transfer of risk away from commissioners of services in terms of transparency and accountability.