Provider diversity in the NHS: impact on quality and innovation

The overall objective of the research project has been to assess the impact of provider diversity on quality and innovation in the NHS. The specific research aims were to identify the differences in performance between non-profit Third Sector organisations, for-profit private enterprises, and incumbent public sector institutions within the NHS as providers of health care services, as well as the factors that affect the entry and growth of new private and Third Sector providers. The study used both qualitative and quantitative methods based on case studies of four Local Health Economies (LHEs). Qualitative methods included documentary analysis and interviews with key informants and managers of both commissioning and provider organisations. To provide a focus to the study, two tracer conditions were followed: orthopaedic surgery and home health care for frail older people. In the case of hospital inpatient care, data on patient characteristics were also collected from the HES database. The analysis of this data provided preliminary estimates of the effects of provider type on quality, controlling for client characteristics and case mix. In addition, a survey of patient experience in diverse provider organisations was analysed to compare the different dimensions of quality of provision of acute services between incumbent NHS organisations and new independent sector treatment centres. The research has shown that, in respect of inpatient hospital services, diverse providers supply health services of at least as good quality as traditional NHS providers, and that there is ample opportunity to expand their scale and scope as providers of services commissioned by the NHS. The research used patient experience survey data to investigate whether hospital ownership affects the quality of services reported by NHS patients in areas other than clinical quality. The raw survey data appear to show that private hospitals provide higher quality services than the public hospitals. However, further empirical analysis leads to a more nuanced understanding of the performance differences. Firstly, the analysis shows that each sector offers greater quality in certain specialties. Secondly, the analysis shows that differences in the quality of patients’ reported experience are mainly attributable to patient characteristics, the selection of patients into each type of hospital, and the characteristics of individual hospitals, rather than to hospital ownership as such. Controlling for such differences, NHS patients are on average likely to experience a similar quality of care in a public or privately-run hospital. Nevertheless, for specific groups of patients and for specific types of treatments, especially the more straightforward ones, the private sector provides an improved patient experience compared to the public sector. Elsewhere, the NHS continues to provide a high quality service and outperforms the private sector in a range of services and for a range of clients.

Innovation in construction: a sociology of technology approach

An alternative approach to understanding innovation is made using two intersecting ideas. The first is that successful innovation requires consideration of the social and organizational contexts in which it is located. The complex context of construction work is characterized by inter-organizational collaboration, a project-based approach and power distributed amongst collaborating organizations. The second is that innovations can be divided into two modes: ‘bounded’, where the implications of innovation are restricted within a single, coherent sphere of influence, and ‘unbounded’, where the effects of implementation spill over beyond this. Bounded innovations are adequately explained within the construction literature. However, less discussed are unbounded innovations, where many firms' collaboration is required for successful implementation, even though many innovations can be considered unbounded within construction's inter-organizational context. It is argued that unbounded innovations require an approach to understand and facilitate the interactions both within a range of actors and between the actors and technological artefacts. The insights from a sociology of technology approach can be applied to the multiplicity of negotiations and alignments that constitute the implementation of unbounded innovation. The utility of concepts from the sociology of technology, including ‘system building’ and ‘heterogeneous engineering’, is demonstrated by applying them to an empirical study of an unbounded innovation on a major construction project (the new terminal at Heathrow Airport, London, UK). This study suggests that ‘system building’ contains outcomes that are not only transformations of practices, processes and systems, but also the potential transformation of technologies themselves.