English Public Hospitals Research Articles

Beyond hollowing out: Public sector managers and the use of external management consultants

AbstractExpenditure on management consultants in public sector organizations is generally seen as contributing to a “hollowing out” of the state through the substitution of internal management capability. However, there is little systematic evidence for this view which also ignores how public sector managers may, themselves, drive consulting use. Looking at 125 English public hospitals over 6 years, we explore the relationship between the development and composition of management functions and spending on consultants. Our findings show the absence of a substitution effect and, therefore, challenge the “hollowing out” thesis. Instead, they point to a more active, occupationally varied and political use of consultancy. We find that larger management functions overall are associated with greater reliance on consultants—a complementary relationship. However, where a higher proportion of managers are engaged in internal consulting functions, this results in the lower use of external management consultants, with implications for theory, research and policy.

Professional Re-Stratification and the (Defensive) Adaptation of Status Hierarchy

Over thirty years since Eliot Freidson’s seminal account of re- stratification and the emergence of administrative elites in professions, we still know little about how far this process has been associated with changes in the criteria for determining seniority and authority. Have new criteria emphasising proven management competency for advancement in professional management hierarchies displaced those of professional status, and if so, under what conditions? In this paper, we investigate this matter focusing on senior medical management roles in English public hospitals. Drawing on a mix of administrative data sources and applying fsQCA, we highlight both change and continuity in the prevailing status hierarchy of medicine. Our findings reveal the continued influence of externally derived professional status criteria for access to the highest-ranking professional manager roles. Additionally, the configurational approach shows how, in situations where hospitals have achieved greater formal autonomy (corporatisation), different criteria emphasising management competency have also been influential.

Nationwide improvement in outcomes of emergency admission for ulcerative colitis in England, 2005‐2013

SummaryBackgroundThe UK IBD Audit Programme reported improved inpatient care processes for ulcerative colitis (UC) between 2005 and 2013. There are no independent data describing national or institutional trends in patient outcomes over this period.AimTo assess the association between the outcome of emergency admission for UC and year of treatment.MethodsRetrospective analysis of hospital administrative data, focused on all emergency admissions to English public hospitals with a discharge diagnosis of UC. We extracted case mix factors (age, sex, co‐morbidity, emergency bed days in last year, deprivation status), outcomes of index admission (death and first surgery), 30‐day emergency readmissions (all‐cause, and selected causes) and outcome of readmission.ResultsThere were 765 deaths and 3837 unplanned first operations in 44 882 emergency admissions, with 5311 emergency readmissions (with a further 171 deaths and 517 first operations). Case mix adjusted odds of death for any given year were 9% lower (OR 0.91, 95% CI: 0.89‐0.94), and that for emergency surgery 3% lower (OR 0.97, 95% CI: 0.95‐0.98) than the preceding year. Results were robust to sensitivity analysis (admissions lasting ≥4 days). There was no reduction in odds for all‐cause readmission, but rates for venous thromboembolism declined significantly. Analysis of institutional‐level metrics across 136 providers showed a stepwise reduction in outliers for mortality and unplanned surgery.ConclusionsRisk of death and unplanned surgery for UC patients admitted as emergencies declined consistently, as did unexplained variation between hospitals. Risk of readmission was unchanged (over 1 in 10). Multiple factors are likely to explain these nationwide trends.

Are Public Sector Managers a “Bureaucratic Burden”? The Case of English Public Hospitals

Although managers are, globally, a central part of the new public management reform agenda, in recent years, policy makers and the media have raised concerns about their effectiveness and contribution. In some countries, notably the United Kingdom and the United States, this debate has been heavily influenced by Public Choice Theory (PCT), which depicts “bureaucrats” as rent seeking, self-serving individuals. In this study, focusing on the case of acute care hospital trusts in the English National Health Service, we formally test whether public sector managers represent a “bureaucratic burden.” Using a longitudinal database spanning six years (2007–2012) and employing a dynamic panel data model, the findings reveal that, contrary to PCT assumptions, managers do not engage, in the main, in rent seeking behavior and, crucially, appear to have a positive impact on organizational performance. Implications for theory, policy, and practice are discussed.

Corporatisation and the Emergence of (Under-Managered) Managed Organisations: The Case of English Public Hospitals

An enduring feature of New Public Management in many countries has been the move to create more autonomous, ‘complete’ organisations such as universities, hospitals and social service agencies. Often referred to as ‘corporatisation’, this process is assumed to be leading to the emergence of new organisational forms with dedicated management functions and a greater focus on strategy. However, these assumptions remain largely untested and rely heavily on ‘technical’ accounts of organisational re-structuring, ignoring the potential influence of institutional pressures and internal political dynamics. In this paper, we address this concern focusing on the case of acute care public hospitals that have undergone corporatisation (to become Foundation Trusts) in the English National Health Service. Using administrative data spanning six years (2007–2012), the analysis shows that corporatisation is having mixed effects. While it is associated with a shift in the focus of managers to strategic concerns, it has not led to an expansion of management functions overall. Both tendencies are found to be mediated by institutional pressures, in the form of media scrutiny, and, indirectly, by the involvement of clinical professions in management. These results advance ongoing debates about the emergence of new organisational forms in the public sector, highlighting the limitations of technical accounts of change and raising the possibility that corporatisation is leading to organisations that are both more managed and under-managered at the same time.

ISQUA16-1955USING ROUTINELY COLLECTED ADMINISTRATIVE DATA TO FURTHER EXAMNE VARIATION IN OBSTETRIC OUTCOMES BY DAY OF THE WEEK

Recent published work demonstrated variation in birth outcomes by day of the week in English Public Hospitals. [1] Over the seven indicators examined, we found a statistically significant association consistent with a lower standard of care for babies born and women admitted over the weekend. The so called “weekend effect”. Perinatal death, injury to the neonate, puerperal infection and three day neonatal readmissions were all …

Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

Objectives To assess the association between mortality and the day of elective surgical procedure. Design Retrospective analysis of national hospital administrative data. Setting All acute and specialist English hospitals carrying...

Failure to Rescue Patients After Reintervention in Gastroesophageal Cancer Surgery in England

Gastroesophageal cancer resections are associated with significant reintervention and perioperative mortality rates. To compare outcomes following operative and nonoperative reinterventions between high- and low-mortality gastroesophageal cancer surgical units in England. All elective esophageal and gastric resections for cancer between 2000 and 2010 in English public hospitals were identified from a national administrative database. Units were divided into low- and high-mortality units (LMUs and HMUs, respectively) using a threshold of 5% or less for 30-day adjusted mortality. The groups were compared for reoperations and nonoperative reinterventions following complications. Both LMUs and HMUs. Patients who underwent esophageal and gastric resections for cancer. Elective esophageal and gastric resections for cancer, with reoperations and nonoperative reinterventions following complications. Failure to rescue is defined as the death of a patient following a complication; failure to rescue-surgical is defined as the death of a patient following reoperation for a surgical complication. There were 14 955 esophagectomies and 10 671 gastrectomies performed in 141 units. For gastroesophageal resections combined, adjusted mortality rates were 3.0% and 8.3% (P < .001) for LMUs and HMUs, respectively. Complications rates preceding reoperation were similar (5.4% for LMUs vs. 4.9% for HMUs; P = .11). The failure to rescue-surgical rates were lower in LMUs than in HMUs (15.3% vs. 24.1%; P < .001). The LMUs performed more nonoperative reinterventions than the HMUs did (6.7% vs. 4.7%; P < .001), with more patients surviving in LMUs than in HMUs (failure to rescue rate, 7.0% vs. 12.5%; P < .001). Overall, LMUs reintervened more than HMUs did (12.2% vs 9.6%; P < .001), and LMUs had lower failure to rescue rates following reintervention than HMUs did (9.0% vs. 18.3%; P = .001). All P values stated refer to 2-sided values. Overall, LMUs were more likely to reintervene and rescue patients following gastroesophageal cancer resections in England. Patients were more likely to survive following both reoperations and nonsurgical interventions in LMUs.

PSU41 Day of Week of Procedure and 30-Day in-Hospital Mortality for Elective Surgery

To investigate whether there is a relationship between the day of the week patients undergo elective surgery and in-hospital death. Retrospective analysis of secondary users service data on adjusted odds ratios for in-hospital death within 30 days of procedure using logistic regression modelling. Patients in acute and specialist English public hospitals undergoing elective surgery over the financial years 2006 to 2008. There were 15,230 in-hospital 30-day deaths as a consequence of 4,197,761 all elective inpatient surgical admissions (an overall crude mortality rate 3.6 per 1000). The overall adjusted odds of death for all elective surgical procedures were 33% and respectively 90% higher if the procedures were carried out on Friday or at Weekend compared to Monday (OR 1.33, 95% CI 1.26-1.41 and respectively OR 1.90, 95% CI 1.75-2.05). This equates to a figure of over 700 excess annual deaths from elective surgery, based on applying Monday mortality rates. The study suggests higher risk of death for patients who have elective surgical procedures carried out closer to the weekend, in particular on Friday. Further research is needed to understand the extent to which the ‘weekday effect' reflects differences in the quality of surgical care.

Inequalities in Stroke Patients' Management in English Public Hospitals: A Survey on 200,000 Patients

BackgroundAccording to clinical guidelines, every patient affected by stroke should be given a brain-imaging scan (BIS) - Computerized Tomography or Magnetic Resonance Imaging - immediately after being admitted to hospital.Aim of the studyTo describe the variation in use of BIS among English public hospitals and identify any patient groups being excluded from appropriate care.MethodsWe collected hospital administrative data for all patients admitted to any English public hospital with a principal diagnosis of stroke from 2006 to 2009. We calculated the proportion of patients treated with BIS in the whole sample and after stratification by hospital. We compared hospitals' performance using funnel plots. We performed a multiple logistic regression analysis using BIS as outcome and age, gender, socio-economic deprivation, and comorbidity as covariates.ResultsIn English public hospitals there are about 70,000 emergency admissions for stroke per year. Nationally, only 35% receive a BIS immediately, and only 84% receive it within the admission. There is large variation in the use of BIS for stroke patients among English public hospitals, with some of them approaching the recommended 100% and some having very low rates. Young (P<0.001), male (P = 0.012), and least socio-economically deprived patients (P = 0.001), as well as patients with fewer comorbidities (P<0.001) appear to have more chance of being selected for a brain scan.ConclusionSome English public hospitals appear to be falling well below the clinical guideline standards for scanning stroke patients and inappropriate patient selection criteria may be being applied, leading to health inequalities.

Multiple Public Service Performance Indicators: Toward an Integrated Statistical Approach

Public service organizations usually produce multiple outputs, measured on different scales, giving rise to a suite of performance indicators. The traditional approach to statistical analysis of organizational performance has been to develop a separate regression model for each performance indicator. This piecemeal approach, the article argues, may discard valuable information, as it ignores potentially important relationships between individual performance measures. We therefore propose modeling an organization’s performance measures simultaneously, using the methods of seemingly unrelated regressions. The approach implicitly introduces a latent organizational variable into the regressions and may therefore economize on the need to assemble explicit measures of organizational characteristics. The method is illustrated using an example from English public hospitals. In most industrialized nations, measuring the performance of public services has assumed central political importance, as governments come under increased pressure to reduce taxation and ensure that tax revenues are spent cost-effectively. To that end, governments have put in place extensive systems for measuring the performance of public service organizations, with a view to improving accountability thorough improved political and managerial scrutiny of those organizations (Bird 2004). Yet only a few years ago such performance data were sparse, selective, and slow to emerge. Now the revolution in information technology is rapidly leading to a situation in which public services are overwhelmed with indicators of activity and performance. In this new world of data overload, an emerging challenge is to turn the data into meaningful messages that are useful for informing both managerial decisions and democratic debate. Without technologies to address this difficulty, there is a risk that the superabundance of data will be used ineffectively. In interpreting performance data, one of the most pressing concerns is often that public service organizations operate in different circumstances, and therefore direct We would like to thank the participants at the Cardiff Seminar, the referees, and our colleagues Katharina Hauck and Andrew Street. Smith is funded by ESRC grant R000271253. Address correspondence to Peter C. Smith at

How much confidence should we place in efficiency estimates?

Ordinary least squares (OLS) and stochastic frontier (SF) analyses are commonly used to estimate industry-level and firm-specific efficiency. Using cross-sectional data for English public hospitals, a total cost function based on a specification developed by the English Department of Health is estimated. Confidence intervals are calculated around the OLS residuals and around the inefficiency component of the SF residuals. Sensitivity analysis is conducted to assess whether conclusions about relative performance are robust to choices of error distribution, functional form and model specification. It is concluded that estimates of relative hospital efficiency are sensitive to estimation decisions and that little confidence can be placed in the point estimates for individual hospitals. The use of these techniques to set annual performance targets should be avoided.