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.     

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.     

RESTRUCTURING THE NHS AGAIN: SUPPLY SIDE REFORM IN RECENT ENGLISH HEALTH CARE POLICY

Introducing market-like structures to public services is a key aspect of New Public Management. The restructuring of the NHS into an internal market of the 1990s is an example. Recent policies have further developed this notion. A new aspect of the restructuring is a focus on increasing the diversity of types of provider of healthcare organisations. The objectives of the restructuring policy entailing the increase in supply side diversity are examined, and the challenges raised by these changes are discussed. It is argued that the government is too optimistic about the benefits, and insufficiently concerned about possible undesirable consequences.     

Loose coupling in asset management systems in the NHS

This paper aims to identify whether the components of a loose-coupled system were present in the asset management systems of the National Health Service (NHS) in Wales and, if so, whether this had a negative impact. By utilising a qualitative analysis of semi-structured interviews with senior officials at two NHS Hospital Trusts together with the findings of a survey of all of the Hospital Trusts in Wales, we conclude that the asset management system of the NHS in Wales exhibits the features of a loosely coupled system with detrimental consequences. Where information on capital assets has been required below board level, lower management relies on local systems, while the information for senior managers and political leaders relies on the management accounting system and ad hoc enquiries. The result has been an impairment of the ability of lower management to reconfigure capital assets which leads to the nation's health service underperforming.     

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.     

New development: Spin-outs and social enterprise: the ‘right to request’ programme for health and social care services

The ‘right to request’ policy encouraged and supported National Health Service (NHS) community health staff in England to ‘spin out’ services into independent social enterprises. This article considers the processes and outputs of the initiative and reflects on the likelihood of positive outcomes for patients being achieved. It highlights lessons for future programmes seeking to transfer services out of public ownership.     

Using contractual incentives in district nursing in the English NHS: results from a qualitative study

Since 2008, health policy in England has been focusing increasingly on improving quality in healthcare services. To ensure quality improvements in community nursing, providers are required to meet several quality targets, including an incentive scheme known as Commissioning for Quality and Innovation (CQUIN). This paper reports on a study of how financial incentives are used in district nursing, an area of care which is particularly difficult to measure and monitor.     

DEVOLUTION, ACCRUALS ACCOUNTING AND ASSET MANAGEMENT IN NHS WALES

This paper describes how a strategy for health services has been developed for NHS Wales and examines the role of accruals accounting in asset management and development. It uses archival investigation as well as interviews and a questionnaire. The role of accruals accounting in the operation of the service, particularly as it relates to the capital asset base of the Trusts and how these are managed, is discussed in the context that Trusts are autonomous units that develop services, and hence their capital asset base, through their own internal planning structure. It is found that, on devolution, there was a lack of consistent information about the stock of capital assets and that capital charges, based on accruals accounting, were not penetrating asset management within individual Trusts. Although strategies were being developed centrally, their implementation at a Trust level can be impeded as a consequence of accruals accounting.     

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 and private sector auditors and accruals quality in English NHS hospital Trusts

To promote auditor independence and audit quality in English NHS Trusts the Audit Commission regulates auditor rotation, fees and the appointment of its own and private sector auditors. NHS sanctioned departures from GAAP, some of which allow the financial breakeven target to be achieved, have been criticised by the Audit Commission as detrimental to financial discipline. In this paper, we investigate the association between abnormal accruals and the achievement of financial breakeven in NHS hospital Trusts over the period 1998–2005. We also investigate the association between abnormal accruals, audit fees and the Trusts audited by public and private sector auditors. We find evidence that abnormal accruals are used to achieve financial breakeven and they differ across different types of auditor. We also identify a negative relationship between abnormal accruals and NHS Trust star ratings. These findings raise questions about the ‘quality’ of NHS audit where compliance with NHS-specific regulations overrides the wider GAAP-based requirement for financial statements to show a true and fair view and they warrant reconsideration of the nature of audit in NHS Trusts.     

THE IMPACT OF POLITICAL INTERESTS UPON THE FORMULATION OF PERFORMANCE MEASUREMENTS: THE NHS STAR RATING SYSTEM

This study examines the impact of political interests of the Blair Government on the development of the NHS star rating system. It argues that the use of performance measurements (PMs) is not detached from its political context but influenced by institutional interests including in particular those of the Government. The analysis indicates that the formulation of the specifics of PM, and of performance information within the NHS star rating system, was skewed to reflect the political objectives of the Blair Government. PMs are not merely neutral instruments, but, suffused with institutional interests, serve as a coercive mechanism to impose pressures upon the NHS as well as seeking to create a public perception of performance improvement. This study concludes that PMs in the public sector are influenced by the need to serve the political interests of the Government.     

Commissioning and GPs: to commit[tee] or not?

Clinical commissioning groups (CCGs), part of the UK's National Health Service (NHS) since April 2013, are complex organizations requiring buy-in by GPs for strategic success. CCG budgetary deficits and lack of sustained engagement by GPs are a problem. This paper utilizes evidence of GP experience in commissioning models to determine the factors that may influence engagement in the governance of CCGs by GPs, which is crucial if clinically-led commissioning is to be part of a financially sustainable NHS.     

Cost-effectiveness and fairness in health care: NICE appraisals

Appraisals by the UK's National Institute for Health and Clinical Excellence (NICE) examine clinical and cost-effectiveness to determine whether medical interventions should be publicly funded by the National Health Service (NHS). NICE's evaluations are attracting increasing debate about the tension between efficiency and equity. This article, using the case of renal cell cancer, argues that NICE is not only concerned with maximized aggregate welfare, but also with its social obligations to protect the less advantaged members of society. The English experience is likely to have international implications in terms of evaluating the benefits of new medical treatments.     

Asset Revaluations in the Accounts of UK National Health Service Trusts

This paper reports the results of an investigation into the impact of the revaluation of fixed assets on the reported results of NHS ambulance services. It recalculates the accounting rate of return of individual trusts after removing revaluation adjustments and examines the published responses of trusts. The numerical analysis demonstrates that, in general, revaluation has depressed the stated rate of return in an inconsistent manner. Failure to meet the required rate of return may cause a trust to be subjected to additional monitoring and management reorganisation while the trusts respond by explaining deviations in the accounting return measure by referring to revaluations and other technical adjustments. Management decisions made in response to these accounting measures may be sub-optimal in delivering health care but appropriate in achieving the desired accounting outcome.     

Comparing the content of regulatory impact assessments in the UK and the EU

The need for effective leadership in the UK public sector has been a prominent discourse in recent years. One aspect of this is a growing interest in talent management. This article examines the evolution of processes used for managing talent and developing leaders in the UK's National Health Service (NHS) by applying human resource management theory to an empirical case study. Our aim was to provide a constructive, but critical, analysis of the current role of managerial talent management and to comment on the suitability of the adopted approach in the NHS. Over the past three decades the NHS has come to adopt an increasingly ‘hard’ approach to talent management, i.e. rationalistic, managerial and narrowly focused on leadership competencies and senior management roles. This parallels a more general shift in the NHS from its traditional public sector ethos and humanistic values to more business-oriented values and ways of working.     

Do We Have a Redundant Set of Cost–Efficiency Targets in the NHS?

There has been a long history of hospital trust cost–efficiency targets being used in the National Health Service (NHS), but there is little evidence about whether they are effective in reducing hospital unit costs and reducing the dispersion of unit costs between trusts. In 1997, the new Labour government announced that it would replace the purchaser efficiency index with a new approach to securing cost–efficiency gains from trusts. Since 1999/2000 trust efficiency targets have been based on reference costs. This article presents evidence to suggest that efficiency targets have not been effective and that the new reference cost based system of targets is irrelevant. The efficiency gains that trusts seek to achieve are those that emerge from the purchaser funding formula and the contracting process.     

The Private Finance Initiative in the National Health Service: An Unhealthy Development in New Public Management?

New Public Management has expanded the role of the private sector in the provision of public services through 'contracting out' the supply of many public service inputs to the private sector. This paper examines the case of the Private Finance Initiative (PFI), which is of increasing importance in extending these inputs to include those of major capital assets, such as hospital buildings. Concerns arise as to whether this process does genuinely increase efficiency and accountability, and over the role of accounting in meeting the new demands being placed upon it, in the context of one of the most sensitive public services, that of health care.     

Complexity and contradiction in NHS computing

The National Health Service (NHS) has entered a new world of managed competition, where the purchasing and provision of services are formally separated. Accompanying the changes are major investments in computer systems, which will continue for at least the first half of the 1990s. However, the performance of the NHS in implementing computer systems has been variable, so that now is an appropriate time to review the current status of NHS computing, and to consider the key issues for computing in the new environment.     

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.     

医疗保险定额付费方式有效性的探讨

医疗保险中的定额付费方式指不论实际发生了多少医疗费用,均以事先确定的标准向医疗机构支付费用,这种支付方式的有效运作意味着可以在控制医疗费用的同时又确保医疗质量.本文认为可能对定额付费方式有效性产生影响的因素包括服务质量对患者诊疗需求的影响程度;医疗机构增加患者诊疗需求的意愿;医疗机构的拒诊和撇脂行为;经办机构在合同签订...