NHS Internal Market Research Articles

Containment lost: the challenge to child psychotherapists posed by modern CAMHS

The paper is an examination of some emotional challenges facing child psychotherapists working in modern CAMHS following the introduction of the NHS internal market for commissioning and providing services. Its introduction has brought the loss of organisational containment for all CAMHS clinicians. The meaninglessness in work reported by clinicians is a clue to this loss. This loss is especially difficult for child psychotherapists because of their particular investment in the apprehension of meaning in symptoms and other presentations by patients. The paper proposes that meaninglessness is itself a clue to the ascendancy of what Freud called the death instinct, and that this is inherent within the internal market model. Because service design and delivery is predicated upon it, the internal market model structurally determines that clinicians are bound to senior management in a way that leaves child psychotherapists open to professional life-threatening dynamics associated with the death instinct. The −K (Bion) world of CAMHS is thus deathly, leaving child psychotherapists vulnerable to self-destruction. We have lost a workplace in which our approach flourished conferring on us the identity of a discipline structurally favoured, because of the help we provided through this approach to patient and clinic work. This loss of identity brings the dangers of containment lost. This situation leaves child psychotherapists emotionally vulnerable and is akin to Satan’s loss in Milton’s Paradise Lost.

With such an NHS staff shortfall, who will work on the ‘mothballed’ wards?

I was interested to read your article about Lord Carter of Coles' report on saving the NHS £5 billion a year (analysis, February 17). However, the article and Lord Carter's report fail to mention the £4.5 billion wasted on the NHS internal market, which adds nothing to patient care according to independent and parliamentary reports into the NHS since 2010.

Competition and Quality: Evidence From the Nhs Internal Market 1991–9

This article exploits policy change by the UK government to identify the impact of competition on quality. It uses differences in competition over time and space to examine the impact of competition in an environment with limited quality signals in which hospitals competed mainly on price. Using AMI mortality as a measure of hospital quality we find that the relationship between competition and this measure of quality is negative. We also find that competition reduced waiting times. Our results indicate that hospitals in competitive markets reduced unmeasured and unobserved quality in order to improve measured and observed waiting times.

The Changing Political Economy of the Nhs

The capacity of the state to delivery healthcare has been affected by a number of factors and is intimately interconnected with the process of globalisation. This has led to a changing political economy and new context for health care financing, not only for the NHS, but for Europe and beyond. This paper considers these changes and explains the process of policymaking that led to the NHS internal market reforms of the 1990s.

Book Reviews

Book Reviews

Does competition between hospitals improve the quality of care?: Hospital death rates and the NHS internal market

Payer-driven competition has been widely advocated as a means of increasing efficiency in health care markets. The 1990s reforms to the UK health service followed this path. We examine whether competition led to better outcomes for patients, as measured by death rates after treatment following heart attacks. Using data that until 1999 were not publicly available in any form on hospital level death rates, we find that the relationship between competition and quality of care appears to be negative. Greater competition is associated with higher death rates, controlling for patient mix and other observed characteristics of the hospital and the catchment area for its patients. However, the estimated impact of competition is small.

Management retention in the NHS.

High turnover amongst middle managers in organisations can lead to strategic instability as well as operational issues. Since the advent of the NHS internal market flatter management structures have led to middle managers being given more responsibilities along with larger spans of control. This has exacerbated the consequences of the high turnover found amongst service managers. This study examines the relationship between the length of time service managers wish to stay with their organisation, their participation in decision making in directorates, the feedback they receive and their perception of feeling valued it outlines the findings from a small study and discusses the implications for health trusts.

Health professionals' views of contracting for infection control in the NHS internal market.

This paper reports a national study which investigated the involvement of infection control professionals in (and their views about) the formal processes of contracting for health care in the NHS internal market. Health care professionals needed to be involved contracting, if it was to be effective. The study found that many infection control professionals were not, in fact, involved in contracting, while the importance of both contracts and informal professional networks were recognised But respondents did not think that their professional networks entirely compensated for their lack of involvement in contracting. As formal agreements continue to be central to achieving quality of care in the post-internal market NHS, infection control professionals need to be involved in specification and implementation of these arrangements.

The use of contracts in the management of infectious disease related risk in the NHS internal market

The paper reports a unique study of contracting for infectious disease control in the English National Health Service internal market. New-institutional economic and socio-legal theories are used to predict that it will not be possible to make contracts for the control of infectious disease which are complete with respect to either the allocation of financial risk or the specification of quality standards. Socio-legal theory predicts that in some circumstances informal relationships (known as networks or relational contracts) can evolve to compensate for some of the deficiencies of incomplete contracts. NHS policy makers are shown to have expected and continue to expect that contracts can be complete. The study comprised five in-depth case studies of contracting in different local areas in England and a national survey of all infection control professionals. The results confirm the theoretical predictions. Contracts were not complete, and some of the elements of relational contracts were present. These elements did not, however, fully compensate for the lack of clear accountability caused by contractual incompleteness.

An empirical analysis of the purchaser-provider relationship in the NHS internal market.

Introduces the relationship marketing paradigm as a means of analysing the purchaser-provider relationship within the NHS internal market. This focus is justified in the context of the limitations of orthodox economic analysis. The research evidence is based upon a national survey of all NHS trust hospitals in England. The survey consisted of key questions relating to the process of relationship building strategies employed by NHS hospital trusts. In particular, emphasis was given to non-price competitive behaviour, i.e. the extent to which health care contracts were augmented or customized by providers. An empirical analysis is presented, identifying those factors driving such non-price competitive behaviour, based upon a LOGIT model. The results suggest the hypotheses tested are consistent with the evidence from our survey. Finally, the model is used to make some tentative predictions regarding the future of the purchaser-provider relationship within the reformed NHS.

Competition, contracting and cost-sharing in the NHS internal market

The NHS Internal Market provided a testing ground for some hypotheses on relationship building between purchasers and providers of secondary health care. An empirical analysis is presented based upon a major survey of NHS Trusts. LOGIT models were used to tackle the qualitative nature of a series of different hypotheses relating to competing MIS Trusts and their risk avoidance strategies. Furthermore, the analysis has been extended to estimate the prevalence of risk avoidance strategies for any specific local health market scenario. The results also enabled some predictions regarding the impact of recent NHS reforms on the relationship building phenomenon.

Learning from the NHS internal market. A review of the evidence edited by Julian Le Grand, Nicholas May and Jo‐Ann Mulligan. King's Fund Publishing, 1998. No. of pages: 145. ISBN 1‐857‐17215‐9. £17.95.

Learning from the NHS internal market. A review of the evidence edited by Julian Le Grand, Nicholas May and Jo‐Ann Mulligan. King's Fund Publishing, 1998. No. of pages: 145. ISBN 1‐857‐17215‐9. £17.95.

Book Review: Learning from the NHS Internal Market: A Review of the Evidence

Book Review: Learning from the NHS Internal Market: A Review of the Evidence

Access to public documents in a study of the NHS internal market: Openness Vs secrecy in contracting for clinical services

This paper describes problems of gaining access to public documents in a qualitative study of the NHS internal market in Wales. Official Department of Health (DoH) guidance stresses the importance of 'openness' and requires contracts between NHS purchasers and providers to be made available on request. However, this study suggests that 'openness' policies do not always translate into straightforward research access, and must be seen as a topic of study rather than an aid to research. The research team experienced considerable difficulty in obtaining full contract documentation; requests were complied with only after follow-up letters; generic 'standard form' drafts were sent in lieu of final contracts; some contract schedules were not supplied with the main documents; and where full contracts were forthcoming, price and activity figures were sometimes omitted or blanked out. Moreover, some contracts depended on a substratum of trust and tacit understandings that were not reflected in the written documents and were not always communicated to the researchers. These problems illustrate the discrepancy that can exist between formal agreements of research access and the defacto secrecy that surrounds some areas of organizational work, where leakage of information might undermine an organization's ability to achieve its goals. Health Authorities were concerned that public scrutiny of contracts would reveal inconsistency in their dealings with different hospital Trusts, particularly regarding the level of penalties to be levied for poor performance. Trusts were concerned that scrutiny would show they were ignoring NHS pricing rules and charging different Health Authorities different tariffs for the same services.

From contracts to service agreements: what can be learned from total purchasing?

Total purchasing is an experimental extension of GP fundholding through which GP practices can purchase community, secondary and tertiary services not included in standard fundholding budgets, for their registered patient populations. The paper presents selected findings from a study of contracting by TPPs during the first year of purchasing, concentrating on the perceived relationship between aspects of the contracting process and the achievement of TPP's strategic objectives. These findings are of relevance to the development of commissioning by primary care groups in light of the Government's proposal that contracts be replaced by long-term service agreements as competition within the NHS internal market is replaced by more collaborative arrangements between commissioners and providers. The paper identifies features of the contracting process which have been instrumental to the achievement of TPPs' service development objectives and may need to be preserved to ensure effective commissioning within the context of the new service agreements.

The effects of regulation and competition in the NHS internal market: the case of general practice fundholder prices

The 1989 reforms of the UK National Health Service introduced competition in supply within a tightly regulated framework. The paper examines whether this competition affects the prices posted by sellers of medical services. We argue that despite regulation market forces may have an impact on price. We test this using the posted prices for one of the two types of buyer, General Practice Fundholders. We find the regulatory rules are not observed, and some evidence of the impact of market forces on price.

Control and accountability in the NHS market: a practical proposition or logical impossibility?

Before the imposition of the NHS internal market, systems of accountability and control were far from adequate and could be criticized on a number of grounds. The market was offered as a panacea to address these inadequacies. However, in practice there have only been partial improvements which could have been achieved without the imposition of the market. The market also creates new problems and a number of crises and scandals seem to be addressed at the political level by pleas to utilize resources more effectively. These pleas mean that more and more the focus is turning back to central planning in the provision of care and further away from so-called market mechanisms. The NHS "managed" market has been imperfect and will continue to be so. Argues that there is no alternative but to return to the planned provision of health care in order to improve on accountability and control in the NHS. Hopefully the adverse impact of the market on clinicians and others will force a more rational reappraisal of the fundamental raison d'être of the NHS and the need for those involved in the delivery of services, at all levels, to be more openly accountable.

Market—what market? A review of Health Authority purchasing in the NHS internal market

This paper argues that the British NHS Reforms (the `Reforms') set out in Working for Patients [1]largely failed to create a market, to achieve the changes that market forces might have been expected to achieve or to meet the objectives set for the NHS in Working for Patients. It draws on the available literature and the author's experience of work with the NHS during the 6 years after Working for Patients. It is hampered, as are all such reviews of the UK Reforms, by the lack of a detailed and systematic research appraisal of the internal market. Many small changes, resulting from market mechanisms, may have occurred throughout the NHS without being publicised or well documented. But overall, there is little convincing evidence that the Reforms have achieved their goals or met the objectives of the politicians who initiated them. The argument here is necessarily limited by the space available (but see [2]for a detailed analysis of the NHS Reforms). The initial sections of the paper examine the characteristics of markets and market power and the extent to which the NHS Reforms created a market, with health authorities and fund-holders as its buyers. The paper concentrates in particular on health authorities. Later sections then examine the extent to which the Reforms met the objectives set out in Working for Patients.

Clinical Audit in the NHS internal market: from peer review to external monitoring

Relations between managers and professionals in the public sector have often centred on the control of work performance. Work performance strategies and techniques have been transformed by recent public sector policies involving managerialisation and quasi-markets. In particular, the clinical audit programme in the National Health Service has traditionally been the preserve of professionals, mainly doctors but managers and purchasers have become more involved recently. Based on an empirical study, this paper explores the ways in which Health Authorities were approaching their responsibilities, the consequences of such strategies for purchasers and providers, and the implications for professional-managerial relations. The paper concludes that purchasers have not made substantial progress in assessing work performance because of professional resistance and the non-threatening environment fostered by some purchasers.

Child Health Surveillance in England and Wales: the bad news.

Postal surveys were conducted in 1993 among all, or samples of, six groups of providers and managers of pre-school child health surveillance (CHS) in England and Wales. Content analyses were also carried out of strategic policy statements for CHS produced by 54 district health authorities in England and Wales. The surveys aimed to document the views and experiences of CHS providers and managers about the impact of recent changes affecting the structure and operation of CHS, including the publication of Health for All Children, the 1990 Contract for General Practitioners (GPs), the implementation of the National Health Service and Community Care Act 1990, and the changing roles of community doctors and health visitors. Four adverse findings from the surveys are discussed: fragmentation in the child health service; the unwanted effects of the NHS internal market; the adverse consequences of the changing role of health visitors; and the concerns voiced by the community doctors about the quality of CHS in general practice.