The NHS Plan: Accounting for investment and reform in twenty acute hospital trusts in England (1998–2003)

The National Health Service (NHS) Plan published in 2000 summarised Labour's commitment to modernising the NHS in England. The NHS would receive substantial additional funding bringing expenditure on health, as a share in national income, to levels comparable with a European average. The promise of secure financing from government promised to reduce uncertainty and facilitate medium term resource planning in the NHS. Extra funding, as outlined in the NHS Plan, would also be tied into capital and labour process reform(s) to ensure that investment translated into the much needed additional capacity to treat patients. During the period 1998–2003 funding for an average acute hospital has increased 50% in cash terms satisfying expectations set out in the NHS Plan. It is now an appropriate time to review progress. Using information collected for 20 acute hospitals, selected on the basis that they had started and completed PFI projects in the period 1998–2003. This paper constructs a physical and financial audit which is then used to reveal the degree to which acute hospital finances are now secure and the extent to which physical capacity to treat patients has been robustly transformed.     

Debate: Local councils' dilemma of planning for uncertainty

The public expenditure implications of PFI projects in Scotland's NHS are substantial. This article compares PFI capital expenditure with projected unitary charges, examines the annual cost of existing PFI schemes and looks at future costs arising from the planned expansion of PFI. Unless the new Scottish National Party-led administration applies the breaks, the annual cost of PFI to Scotland's NHS is to increase almost five-fold, from £107.1 million in 2005/06 to £500 million by the early part of the next decade.     

Comparing NHS Hospital Unit Costs

Efforts to improve the efficiency of the hospital sector in the National Health Service (NHS) have concentrated on measuring the unit costs of service provision. Hospitals identified as having high unit costs are considered poor performers. Several indices have been constructed to measure unit costs. These produce conflicting messages: hospitals with relatively high unit costs as measured using one index may have low unit costs according to another index. Furthermore, the publication of cost information may lead to unintended consequences and perverse behaviour, rather than genuine performance improvements. To get a more accurate picture of performance, cost information should be included within a broader performance assessment framework for hospitals.     

Austerity and Hospitals in Deficit: Is PPP Termination the Answer?

While austerity is commonly presented as a necessary, although undesirable, reduction in public expenditure, this framing may disguise a re-imagining of the state whereby governments seize the opportunity of economic difficulties to shrink the state. This paper offers a critical examination of the nature of austerity by exploring the case of the UK's National Health Service (NHS), which according to political rhetoric is protected from austerity cuts. However, in the context of eight years of historically low funding growth coupled with increasing demand pressures from a growing and ageing population, the NHS has for several consecutive years faced substantial overspending by NHS provider organizations. With the Government intent on continuing its deficit and debt reduction path within a framework of ‘austerity’ focused almost exclusively on the expenditure side, NHS organizations have begun to explore radical solutions for reducing their costs. Following reported savings obtained by the early termination of a PPP contract at the Hexham General Hospital, politicians and some NHS managers have considered whether this experience might be repeated elsewhere. Our aims in this paper are to examine the financial feasibility of responding to the pressures created by austerity in this particular way, and to challenge the notion that the NHS has been protected from austerity. We extend the evidence base on PPP contract termination and analyze statistical information and financial statements in the public domain to highlight the legal and financial realities of early PPP termination.     

Pricing in the English NHS quasi market: a national study of the allocation of financial risk through contracts

The authors investigated how the formal national provisions for pricing in the National Health Service (which are a form of prospective payment, known as ‘Payment by Results’) are operationalized at local level. Transactions costs theory and existing evidence predict that actual practice often does not comply with contractual rules. A national study of pricing between 2011 and 2015 confirms this and indicates that such payment systems may not be appropriate to address the current financial and organizational challenges facing the NHS. As the NHS struggles radically to reconfigure services, it is necessary to reconsider the appropriateness of a wider range of pricing mechanisms to facilitate moving care out of hospitals.     

Public sector borrowing requirement: A plain man's guide

With the implementation of an internal market in the UK National Health Service (NHS), interest in marketing NHS services is growing. Yet marketing practice in other sectors of the economy, and the experience of other markets in health care, raise doubts and objections as to whether marketing should be introduced in the NHS at all. Some of these objections have force, and there are important structural differences between the NHS internal market and conventional markets. Simply copying conventional marketing methods is therefore unlikely to be an effective, or even a desirable, approach to marketing in the NHS. Specific forms of marketing are required for the NHS and these forms differ for purchasing organizations, for commercialized health care providers (including NHS trusts), and for directly‐managed NHS services. Differences between these variants can be illustrated by considering the different ways in which a generic model of marketing would have to be amended for each case. The differences also suggest some policy and managerial parameters for the future development of NHS marketing.     

Adapting not Adopting: 1958 - 74. Accounting and Managerial 'Reform' in the Early NHS

This paper examines accounting and managerial reform in the public sector National Health Service (NHS) hospitals in the UK from 1958-74. This period is often regarded as one of 'consolidation' (Klein, 1995; Webster, 1998) after the 'turmoil' of the early years of the NHS, though there were a number of attempts to improve 'efficiency' through initiatives largely rooted in commercial practice. There was a deeply embedded respect for local self governance rather than central 'command and control' (Harrison, 1988; Klein, 1995) and more ambitious reforms were avoided. Accounting practitioners and senior civil servants appeared to be content to adjust existing accounting processes rather than embrace major change. The paper concludes with a review of possible factors mitigating against more radical accounting innovation.     

Accounting for Public Hospitals: A Case Study of Modified GAAP

Public hospitals in the U.K. apply GAAP as modified by the Treasury, the Financial Reporting Advisory Board (FRAB) and the Department of Health. Individual National Health Service (NHS) Trusts apply their interpretation of the accounting manuals with further guidance and scrutiny from oversight bodies such as the Audit Commission. This article uses a case study approach to investigate how GAAP is modified and to outline the consequences of the constructed reality. The modifications are layered and often opaque. The accounts are constructed according to accounting requirements stipulated by Government and the account preparers adapt the requirements at Trust level. The accounting statements play a part in constructing a reality ( Hines, 1988 ) that has consequences through the NHS control regime and in how the financial position is portrayed to the public. It appears that GAAP is used to legitimate the NHS as a modern organization applying commercial accounting practice, but the accounting statements provide a distorted view of GAAP compliant statements. The accounting, while not itself real, is real in its consequences and can lead to biased decision‐making, service closures and job losses. The planned compliance of NHS Trusts with international GAAP may provide further scope for modification and manipulation in constructing NHS accounting reality.     

NHS CAPITAL INVESTMENT AND PFI: FROM CENTRAL RESPONSIBILITY TO LOCAL AFFORDABILITY

At its inception, the NHS was structured as a public corporation, which owned its hospitals. Sixty years on, hospitals are business units or Trusts, which are responsible for capital investment in a local region. The Private Finance Initiative (PFI) has become the predominant mode of financing new hospitals. This paper's purpose is to review the impact of PFI. A literature review traces the various stages of the NHS' hospital investment programme and the research method is a case study. The findings show that PFI is leading to additional costs and complexity that make the achievement of the NHS's objectives difficult.     

人口老龄化对住院费用增长的贡献——基于CFPS数据的分析

在中国,许多人认为,人口老龄化是医疗费用增长的主要驱动力,极度担忧人口老龄化带来医疗费用的快速膨胀。本文首先利用CFPS 2010年和2012年的调查数据,计算了2009-2011年间中国(老年)人口年龄结构变动和(老年)人口数量变动对住院总费用增长的贡献。接下来,利用2009年和2011年全国人口抽样调查数据进行了校正。结果发现,(老年)人口年龄结构变动不是住院医疗费用增长的主要原因,(老年)人口数量剧烈变动可能对住院医疗费用增长产生较大的影响。但是,就中国现实而言,不论是人口老龄化还是老年人口数量变动,对中国住院费用增长的贡献均极其有限。这既是因为人口老龄化本身的速度很慢,老年人相对于非老年人的平均住院费用较低,并且老年人平均住院费用随年龄升高而下降,也是因为中国年龄别平均住院费用增长过快。为此,未来应进一步提高老年人医疗保障水平,加强慢性病预防和康复体系建设,关注医疗保险支付方式改革,遏制医疗技术快速发展和医师诱导需求现象,以控制医疗费用快速上涨。     

The Wider Impacts of the Coronavirus Pandemic on the NHS*

The coronavirus pandemic has had huge impacts on the National Health Service (NHS). Patients suffering from the illness have placed unprecedented demands on acute care, particularly on intensive care units (ICUs). This has led to an effort to dramatically increase the resources available to NHS hospitals in treating these patients, involving reorganisation of hospital facilities, redeployment of existing staff and a drive to bring in recently retired and newly graduated staff to fight the pandemic. These increases in demand and changes to supply have had large knock-on effects on the care provided to the wider population. This paper discusses likely implications for healthcare delivery in the short and medium term of the responses to the coronavirus pandemic, focusing primarily on the implications for non-coronavirus patients. Patterns of past care suggest those most likely to be affected by these disruptions will be older individuals and those living in more deprived areas, potentially exacerbating pre-existing health inequalities. Effects are likely to persist into the longer run, with particular challenges around recruitment and ongoing staff shortages.     

Does Medical Equipment Expansion Lead to More Diagnostic Services? Evidence from China’s Sichuan Province

A major goal of China’s healthcare reform is to control the increasing healthcare spending, much of which can be attributed to the overuse of diagnostic tests and has been relatively less studied in the literature. This article analyzes the correlation between medical equipment expansion and the increase in diagnostic test expenditure in China, using Sichuan Province as an example. County-level data aggregated from hospitals’ annual reports in Sichuan Province from 2008 to 2012 were used. The results show a positive correlation between the expansion of medical equipment and the increase in diagnostic test expenditure. Our study provides implications on reforming China’s healthcare delivery system and medical equipment regulation policies.     

The Attitudes of British National Health Service Managers and Clinicians Towards the Introduction of Benchmarking

This paper describes an empirical study, conducted in three acute hospitals, of the attitudes of central managers, medical managers and clinicians towards the adoption of benchmarking. Benchmarking was portrayed in The New NHS White Paper (1997) as an important means of improving efficiency over the next decade. The present paper examines the context of change and nature of benchmarking. Findings are presented in seven sections including: the understanding which respondents had of benchmarking; their willingness to be involved in benchmarking; the existence of strategies and policies for implementing benchmarking; the relevance of existing costing information; and the role of networks in facilitating benchmarking. The study concludes that the process of change adopted contradicted most of the factors associated with creating receptivity to change. Also, that the publication of the National Reference Costs seemed to have more relevance to resource planning at central National Health Service Management Executive level, than to effecting improvements at operational level in acute hospitals.     

论公共卫生最优支出策略

公共卫生支出具有极强的正外部性.如果由地方政府或私人选择公共卫生支出的水平,那么他们的最优选择是较低的公共卫生支出和较高的个人消费(内含个人医疗支出),整个社会的福利将会处于较低的水平状态.本文在一个动态的框架下分析了发生这种现象的经济学原因,说明中央政府而非地方政府或私人应该对公共卫生的建设承担更大的责任,应由中央政府负责全国公共卫生体系的建设.     

Delivering patient choice in English acute hospital trusts

The role of the patient within the NHS has changed from supplicant to consumer to active participant. A demand-side patient-led approach is combining quasi-consumerism and participative democracy to inform and facilitate patient choice. On the supply-side funding and incentives coupled to reform and performance will deliver additional hospital capacity and patient choice. This paper argues from both a demand and supply-side perspective that there is a large gap between the rhetoric and reality of delivering patient choice in acute hospitals.     

我国财政支农支出促进农民收入增长的实证分析

实证检验改革开放以来我国财政支农支出对农民收入增长的效应,财政支农支出对农民收入增长具有正的效应,说明财政支农支出在一定程度上促进了农民收入增长。因此,要采取切实措施,优化并扩大我国财政农业支出,从而促进我国农民收入快速增长。     

关于构筑我国公共财政支出框架的思考

适应市场经济改革，构筑公共财政支出框架是我国下一步财政支出改革的目标和方向。借鉴西方公共财政理论政策的同时，应结合我国的现实国情通盘考虑。构筑新财政支出框架时，既要满足公共财政的一般性要求，又要结合我国财政的特殊性要求，两者并重，不可偏废。在合理界定财政支出职能范围的基础上，通过提高支出总量、优化支出结构、加强支出管理、构筑适合我国国情的公共支出框架。     

Costing a Secure NHS Network

Much debate has surrounded the development of computer networks in the National Health Service (NHS), particularly in connection with perceived threats to the confidentiality of patient records. Cryptography has been proposed as a means of protecting such information although significant costs are involved, not simply because modifications have to be made to existing computer equipment and software, but because of new administrative overheads. There is a danger that the complexities of implementation, and the costs which derive from them, will be under-estimated. Lessons should be applied from previous IT projects in the NHS, in which initial vagueness in definitions of scope and cost were identified as one of a number of factors likely to contribute to project failure.     

转型期我国财政支出结构与经济增长关系研究

通过数理方法对我国转型时期的财政支出结构及其与经济增长的关系进行分析研究,发现当前我国财政支出结构不尽合理,必须进一步优化.要严格控制财政直接用于一般竞争性领域,逐步加大对农业、就业和社保、环境和生态、公共卫生、教育和科技等经济社会发展薄弱环节的投入力度.同时要结合财政体制改革和其他配套改革,以提高财政支出效益.