Cost-based pricing in the NHS internal market : accounting choices and the achievement of economic efficiency

Since 1988, quasi-markets have been introduced into many areas of social policy in the UK, the NHS internal market is one example. Markets operate by price signals. The NHS Internal Market, if it is to operate efficiently, requires purchasers and providers to respond to price signals. The research hypothesis is - cost accounting methods can be developed to enable healthcare contracts to be priced on a cost-basis in a manner which will facilitate the achievement of economic efficiency in the NHS internal market. Surveys of hospitals in 1991 and 1994 established the cost methods adopted in deriving the prices for healthcare contracts in the first year of the market and three years on. An in-depth view of the costing for pricing process was gained through case studies. Hospitals had inadequate cost information on which to price healthcare contracts at the inception of the internal market: prices did not reflect the relative performance of healthcare providers sufficiently closely to enable the market's espoused efficiency aims to be achieved. Price variations were often due to differing costing approaches rather than efficiency. Furthermore, price comparisons were often meaningless because of inadequate definition of the services (products). In April 1993, the NHS Executive issued guidance on costing for contracting to all NHS providers in an attempt to improve the validity of price comparisons between alternative providers. The case studies and the 1994 survey show that although price comparison has improved, considerable problems remain. Consistency is not assured, and the problem of adequate product definition is still to be solved. Moreover, the case studies clearly highlight the mismatch of rigid, full-cost pricing rules with both the financial management considerations at local level and the emerging internal market(s). Incentives exist to cost-shift, and healthcare prices can easily be manipulated. In the search for a new health policy paradigm to replace traditional bureaucratic provision, cost-based pricing cannot be used to ensure a more efficient allocation of healthcare resources.

Corporate governance in the NHS

Corporate Governance - which is concerned with the management and direction of organizations at the very highest level - has grown in importance in the private sector, from where the concept largely derives, as a result mainly of malpractice. As a consequence, interest in the topic has grown steadily, largely on the part of Governments, regulators and academics. Managerial reforms of the NHS introduced refashioned District Health Authorities (DHAs) which mimic the role and structure of the Company board. The research reported in this thesis is an assessment of corporate governance in post reform English DHAs. The research examines the characteristics of directors, the extent to which corporate governance can be empirically demonstrated, the extent to which it is consistent with the Working for Patients reforms, and, the consequences of such changes for the development of directors and of DHAs. The research also considers the relevance of the findings to other parts of the NHS and public sector. The work draws upon the conceptual framework established by Tricker (1984; also Hilmer & Tricker 1991) with detailed survey and case study findings concerned with issues of direction, executive management, supervision and accountability. The findings from this new research make an important contribution to the policy debate and to the literature(s) concerned.

Control of antibiotic prescribing in UK NHS hosptials. Available in 2 volumes.

This thesis is an evaluation of practices to control antibiotic prescribing in UK NHS hospitals. Within the past ten years there has been increasing international concern about escalating antibiotic resistance, and the UK has issued several policy documents for pmdent antibiotic prescribing. Chief Pharmacists in 253 UK NHS hospitals were surveyed about the availability and nature of documents to control antibiotic prescribing (formularies, policies and guidelines), and the role of pharmacists and medical microbiologists in monitoring prescribers' compliance with the recommendations of such documents. Although 235 hospitals had at least one document, only 60% had both an antibiotic formulary and guidelines, and only about one-half planned an annual revision of document(s). Pharmacists were reported as mostly checking antibiotic prescribing on every ward whilst medical microbiologists mostly visited selected units only. Response to a similar questionnaire was obtained from the Chief Medical Microbiologists in 131 UK NHS hospitals. Comparisons of the questionnaires indicated areas of apparent disagreement about the roles of pharmacists and medical microbiologists. Eighty three paired-responses received from pharmacists and medical microbiologists in the same hospital revealed poor agreement and awareness about controls. A total of 205 institutional prescribing guidelines were analysed for recommendations for the empirical antibiotic prescribing of Community-Acquired Pneumonia (CAP). Variation was observed in recommendations and agreement with national guidance from the British Thoracic Society (BTS). A questionnaire was subsequently sent to 235 Chief Pharmacists to investigate their awareness of this new guidance from the BTS, and subsequent revision of institutional guidelines. Documents had been revised in only about one-half of hospitals where pharmacists were aware of the new guidance. An audit of empirical antibiotic prescribing practices for CAP was performed at one hospital. Although problems were experienced with retrieval of medical records, diagnostic criteria were poorly recorded, and only 57% of prescribing for non-severe CAP was compliant with institutional guidelines. A survey of clinicians at the same hospital identified that almost one-half used the institutional guidelines and most found them useful. However, areas for improvement concernmg awareness of the guidelines and ease of access were identified. It is important that hospitals are equipped to react to changes in the hospital environment including frequent movement of junior doctors between institutions, the employment of specialist "infectious diseases pharmacists" and the increasing benefits offered by information technology. Recommendations for policy have been suggested.

Community pharmacy in a commissioning-led NHS:can pharmacy compete effectively?

Introduction – The commissioning of services has been a core responsibility of English Primary Care Trusts (PCTs) since 2002. Primary care organisations (PCOs) in Scotland, Wales and Northern Ireland have also increased their commissioning activities but with, arguably, less fervour than their English counterparts. The commissioning function of English PCTs has been reinforced by the introduction of new contractual frameworks across primary care – for medical services, dentistry and pharmacy. The new pharmaceutical services contract for England and Wales introduced an “enhanced” category of services, the provision of which is dependent on the commissioning decisions of local PCTs. As the NHS, most pertinently in England, continues its transformation from a provider to a commissioner of healthcare, the ability of pharmacy to compete effectively for funding is likely to become increasingly important. Method - After piloting, in August 2006 a self-completion postal questionnaire was sent to a random sample of practising community pharmacists, stratified for country and sex, within Great Britain (n=1998), with a follow-up to non-responders 4 weeks later. Data were analysed using SPSS (v12.0). A final response rate of 51% (n=1023/1998) was achieved. Within the section of the questionnaire relating to service provision, respondents were asked “do you believe that pharmacy will be able to compete effectively with other healthcare providers for access to additional funding to develop services that address a public health need identified by your local Primary Care Organisation (PCO), e.g. PCT/LHB etc.?”. Answers were recorded on a three-point scale; pharmacy “will”, “may”, or “will not” be able to compete effectively for funding. Results - The attitudes of pharmacists showed variation depending on the type of pharmacy they worked in (supermarket, multiple (outlets (n)=200), large chain (200>n>20), small chain (20=n>5), or independent (n=5)) (?2 test with p=0.001). Over a third of survey pharmacists working in small chains and independents (37% (n=21/57) and 33% (n=113/341) respectively) believed that pharmacy would not be able to compete effectively for funding compared to 23% (n=15/65) for supermarket pharmacists, 22% (n=21/97) for pharmacists employed by large chains and just 18% (n=62/353) for pharmacists employed most regularly in multiples. Furthermore, attitudes also varied between the countries of residence of respondents (?2 test with p<0.05). 27% (n=242/893) of pharmacists resident in England and Wales believed that pharmacy would not be able to compete compared to 16% (n=18/116) of pharmacists resident in Scotland. Conclusions – It would appear that community pharmacists believe that the larger pharmacy chains and supermarkets will occupy an advantageous position in terms of attracting finance to develop services. This could have notable implications for service provision across the sector. If corporate pharmacy chains were to monopolise commissioning monies then the proportion of funding available to independents will be diminished; arguably further hastening their demise, as well as stifling the professional development of pharmacists employed within the independent sector. These findings, when combined with the variation observed between UK pharmacists operating under different contractual frameworks, may be a reflection of the divergent policy in the different administrations with developments in England, including the new pharmacy contract, reflecting a market-based approach with Scotland taking a near opposite stance with service integration and a commitment to new public health. However, it should be acknowledged that the questionnaire did not allow for detection of ambiguities in, or misunderstandings of, the survey question and this should be considered as a limitation of the research.

Professionals' awareness of operational antibiotic prescribing controls in UK NHS hospitals

In recent years, there have been increasing recommendations for multidisciplinary collaboration between clinical pharmacists and medical microbiologists in an attempt to control the quality (and quantity) of antibiotic prescribing. A questionnaire addressing the utilization of antibiotic prescribing controls was sent to the chief pharmacist and medical microbiologist in UK NHS hospitals. Responses were received from both the chief pharmacist and the medical microbiologist employed in the same hospital from 83 hospitals (a 30% response rate from two independent studies). A high level of disagreement and poor awareness was identified between the interprofessional staff groups regarding the existence of antibiotic formulary (with disagreement between the two groups, or not known by one or both respondents, in 46% of the paired hospitals, N=38) and guideline documents (13%, N=11), performance of antibiotic prescribing audits (40%, N=33), and whether pharmacists (52%, N=43) and medical microbiologists (77%, N=64) monitored physician compliance with antibiotic prescribing control documents. This study has identified poor knowledge of the existence of basic antibiotic prescribing control mechanisms and the role of professional colleagues. It is suggested that there is some way to go before 'Agenda for Change' principles of flexible and collaborative roles are met. © 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

The micro-politics of operational adjustment:veto players and the consolidation of demand in the NHS

Recent reports about procurement within the NHS have been highly critical. One problem identified in the reports is the fragmentation of NHS demand across an unnecessarily large number of suppliers. This fragmentation is said to increase transaction costs, reduce opportunities for scale economies and reduce NHS leverage over suppliers. It has been suggested, therefore, that an important way of improving procurement in the NHS is the better consolidation of demand with a lower number of preferred suppliers. However, such a policy, because it will create ‘winners’ and ‘losers’ within NHS organisations, has political as well as technical and practical ramifications. In this article, the authors present a model, the Veto Players Model, in order to assist managers to address these political ramifications. In the article, the authors not only demonstrate the utility of this model with regard to demand consolidation policies, but also argue that the model provides useful lessons for change management initiatives more generally.

Bent v Central Manchester University Hospitals NHS Trust 2012

Case law report - online

North Bristol NHS Trust v Harrold 2012

Case law report - online

Thor v Royal Free Hampstead NHS Trust 2012

Case law report - online

Piper v Maidstone and Tunbridge NHS Trust 2012

Case law report - online

Sandford and Parkin v Newcastely upon Tyne Hospitals NHS Trust 2012

Case law report - online

The perceptions of the NHS managers towards the recent NHS reforms and their effects on the NHS managerial culture

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Policy through procurement:introduction of digital signal process (DSP) hearing aids into the English NHS

Despite being a major user of many technologies and innovations, the healthcare sector's role and influence as a procurer of technologies has been poorly represented by the literature and consequently is not fully understood. Providing a practical example of the introduction of digital signal process (DSP) hearing aids in to the English NHS, this paper discusses the role of public sector procurement agencies in the uptake of technologies from the private sector and their adoption by the public sector. Employing a system of innovation (SI) approach, the paper highlights the need for policy-makers to adopt a dynamic as well as systemic perspective that recognises the shifting roles, responsibilities and interactions of key stakeholders throughout the innovation process.

A KM perspective on implementing an electronic patient record within an NHS hospital

The Electronic Patient Record (EPR) is being developed by many hospitals in the UK and across the globe. We class an EPR system as a type of Knowledge Management System (KMS), in that it is a technological tool developed to support the process of knowledge management (KM). Healthcare organisations aim to use these systems to provide a vehicle for more informed and improved clinical decision making thereby delivering reduced errors and risks, enhanced quality and consequently offering enhanced patient safety. Finding an effective way for a healthcare organisation to practically implement these systems is essential. In this study we use the concept of the business process approach to KM as a theoretical lens to analyse and explore how a large NHS teaching hospital developed, executed and practically implemented an EPR system. This theory advocates the importance of taking into account all organizational activities - the business processes - in considering any KM initiatives. Approaching KM through business processes allows for a more holistic view of the requirements across a process: emphasis is placed on how particular activities are performed, how they are structured and what knowledge demanded and not just supplied across each process. This falls in line with the increased emphasis in healthcare on patient-centred approaches to care delivery. We have found in previous research that hospitals are happy with the delivery of patient care being referred to as their 'business'. A qualitative study was conducted over a two and half year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non- participant observation of meetings and documentary data. We believe that the inclusion of patients within the study may well be the first time this has been done in examining the implementation of a KMS. The theoretical propositions strategy was used as the overarching approach for data analysis. Here Initial theoretical research themes and propositions were used to help shape and organise the case study analysis. This paper will present preliminary findings about the hospital's business strategy and its links to the KMS strategy and process.