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Autonomy and l ocal relationships in the English NHS Mark Exworthy - M.Exworthy@rhul.ac.uk

Paper presented to the European Health Management Association conference, Athens, 25-27 June 2008. Autonomy and l ocal relationships in the English NHS Mark Exworthy - M.Exworthy@rhul.ac.uk Francesca Frosini – Francesca.Frosini@rhul.ac.uk Lorelei Jones - Lorelei.Jones@lshtm.ac.uk.

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Autonomy and l ocal relationships in the English NHS Mark Exworthy - M.Exworthy@rhul.ac.uk

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  1. Paper presented to the European Health Management Association conference, Athens, 25-27 June 2008 Autonomy and local relationships in the English NHS Mark Exworthy - M.Exworthy@rhul.ac.uk Francesca Frosini – Francesca.Frosini@rhul.ac.uk Lorelei Jones - Lorelei.Jones@lshtm.ac.uk Research funded by NHS SDO R&D programme http://www.sdo.lshtm.ac.uk/sdo1252006.html

  2. Outline • Conceptual background • Vertical and horizontal autonomy • “Decision space” in local health economies • Empirical study from the English NHS • Emerging findings 1

  3. Conceptual Background Vertical and horizontal autonomy Vertical Autonomy Horizontal Autonomy Bossert T. (1998). ‘Analyzing the decentralisation of health systems in developing countries: decision space, innovation and performance’. Social Science and Medicine, 47, 10, pp.1513-1527 Exworthy M. and Frosini F. (2008).’Room for manoeuvre? Explaining local autonomy in the English National Health Service’. Health Policy, 86, pp204-212 2

  4. Conceptual background: “Decision Space Framework” Central Policies Government Decision Space/ Vertical Autonomy Incentives Directed Change Social and Institutional Embeddedness Local Level Local Choice Innovation No Change Outcomes Performance Performance Performance 3

  5. The structure of the NHS

  6. Local Gvt Vertical and Horizontal autonomy in the NHS: the Local Health Economy Non local PCTs Horizontal / Local Relationships Vertical Autonomy Local PCT NHS Trusts Foundation Trust Non local PCTs Clinical Networks Financial Flows 13

  7. The Study Methodology • Comparative longitudinal case-study of 2 contrasting LHEs (2006-2009) • This presentation reports from phase 1 in one LHE • Data collection • Interviews with 23 clinicians and managers • Observation at public and private meetings • Documentary / secondary data analysis 13

  8. Findings • Multiple contradictory policies • Rapid pace of change 2

  9. Findings • In the context of policy turbulence and upheaval, organisational performance is associated with long-standing relationships that engender trust

  10. Performance associated with long-standing relationships [Forest Hospital] has also been very reluctant to give up the OG cancer which I talked about, so there's lots of tensions between our organisations but the clinicians just kind of, just get on with it really, you know just … so a few little chats in the room together and man- it's the management that find it difficult Cathy, General manager - surgery, County General

  11. Findings Persistence of social and institutional relations Disruption of social and institutional relations 2

  12. Persistence of social and institutional relations Loyalty of patients to local providers We will offer a patient five places to go and appointment times at those five places- that's what it says, it doesn't mean it's going to be within your county, or within you district, it's anywhere within the country, so- so all she does is she logs out of the Choose & Book screen and writes me a letter and sends it in, so I mean, so that's all that's happening, there is no choice- patients don't want choice, patients want to be treated in their local hospital Bob, Clinical Director of orthopaedics, Forest Hospital

  13. Disruption of social and institutional relations New Staff Well it's difficult because you- you just have to you know, new people come and you end up with a different set of relationships, sometimes that's been helpful, sometimes it's been less helpful but you know, it has caused some difficulties where you develop some strategic alliances and you know, new people come in and want to change those alliances for all sort of you know, reasons and you know, that can disrupt continuity Chris, CEO, Forest Hospital (FT)

  14. Disruptions of social and institutional relations Reconfiguration ...and I mean it- it brought out I think in that situation often brings out the worst in people and sours relationships which then take a long time to recover so I think it's been very detrimental to the area and probably the reason why we're now thinking about joining with [the other hospital] as opposed to- some might say the more logical thing is for us to join with County hospital first and then go West, sorry go East towards [the other hospital] is that the relationships between us and [County] hospital have been soured by, I think, by the whole process, so it wasn't a particularly constructive or useful thing to go through. Bob, Clinical Director of orthopaedics, Forest Hospital

  15. Consequences Persistence of social and institutional relations Disruption of social and institutional relations Autonomy and collaboration 2

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