THE IMPACT OF FUNDHOLDING ON PRIMARY HEALTH CARE: ACCOUNTS FROM SCOTTISH GPS

At the inception of the internal market in health care GP fundholding was seen rather as a 'sidesho' to the main reforms. But as the reforms have worked through, GP fundholding has emerged as pivotal to the purchaserlprovider agenda and the changes now associated with GP fundholding will be major issues in directing future health care policy initiatives. Drawing on empirical data from three Scottish regions, this paper argues that fundholding is now significant because GPs perceive benefits for primary health care. The paper uses the data collected from the case studies in the regions to assess these gains on two levels: the 'micro' impact of fundholding on primary health care processes and the 'macro' issues raised for health care policy by involving GPs more closely in resource management. Some GPs wish to use resource management as a vehicle for enhancing equity within the NHS, others are more concerned to manage resources so as to expand their practices into sites which combine primary, secondary and community health care, still others envisage developing the market to include monetary rewards for 'efficient' practices.     

Went Fundholding, Going Commissioning? Some Evidence-Based Reflections on the Prospects for Primary Care Groups

Following the publication of the White Paper, 'The New NHS: Modern, Dependable' (Cm 3807), the Labour Government has abolished GP fundholding. Family doctors retain a lead role for primary care in planning health care with the creation of Primary Care Groups (PCGs). In due course, it is expected that health authorities will relinquish direct commissioning of care to PCGs. Although fundholding is ending, its operation provides useful evidence about how GPs approach participation in the planning of health care. This article reflects on the prospects for PCGs, drawing on original research into the reasons why practices volunteered to 'go fundholding' and how those practices selected their 'lead' partner, on whom much of the fundholding burden fell.     

GP PRACTICE BUDGETS: AN EVALUATION OF THE FINANCIAL RISKS AND REWARDS

This paper considers the progress to date of those GP practices which have decided to become fundholding practices. We note that already, within the first year of operation, both GP fundholders and District Health Authorities have developed a number of budget ploys. As part of our work we report on the findings of a pilot survey of GP budget holders in the Kent Family Health Service. We conclude that if budget holding becomes the normal pattern of general practice, there will need to be a considerable development of the financial skills and managerial capabilities of the practices and it may be time for the new GP practice manager to come of age.     

Developing Primary Care Groups in the New NHS: Towards Diversity or Uniformity?

This article examines how the Government's 'third way' is being implemented in relation to the involvement of primary care professionals in the commissioning of health services. Prior to 1997, the single preferred model of GP fundholding evolved into a diversity of approaches to commissioning and these approaches became increasingly collaborative rather than competitive. From this starting point, the authors examine the key assumptions underlying the present single model of the primary care group (PCG) as the commissioning body for the 'New NHS'. They suggest that PCGs will also evolve into a diversity of models, but there will be tensions arising over the greater emphasis on central direction and performance management.     

The Nature of Business Planning Undertaken by General Practitioner Fundholding Practices in the North West Region

This article focuses on a central feature of the former Conservative Government's approach to the National Health Service (NHS), the introduction of General Practitioner Fundholding. It examines the nature of business planning undertaken by fundholding practices in the North West Region by looking at the participation of various stakeholders in the business planning process, the business planning techniques adopted and the extent to which fundholding practices set and monitor their objectives.     

Mustn't Grumble: Immigration,Health and Health Service Use in the UK and Germany*

A rise in population caused by increased immigration is sometimes accompanied by concerns that the increase in population puts additional or differential pressure on welfare services, which might affect the net fiscal contribution of immigrants. The UK and Germany have experienced significant increases in immigration in recent years and this study uses longitudinal data from both countries to examine whether immigrants differ in their use of health services from native-born individuals on arrival and over time. While immigrants to Germany, but not the UK, are more likely to self-report poor health than the native-born population, the samples of immigrants use hospital and GP services at broadly the same rate as the native-born populations in both countries. Controls for observed and unobserved differences between immigrants and native-born sample populations make little difference to these broad findings.     

Beyond the contract: Managing risk in supply chain relations

As a consequence of the development of intensified relations with suppliers, for many firms the supply chain has become a significant source of risk exposure. In this paper we examine firms’ use of control practices to manage risks associated with intensified collaboration with supply chain partners. Specifically, we examine how buyers manage risks associated with interfirm transactions through their choice of supply partner, in terms of perceived goodwill and competence trust, and their use of multiple interrelated supply chain management (SCM) control practices. These control practices include contractual contingency planning, performance target setting, operational reviews, information sharing, supplier support and joint problem solving. We collect survey data from Japanese manufacturing firms about their relations with part suppliers to test hypotheses about the associations between transaction risks, selection of trusted suppliers and use of SCM practices. Our results support that transaction characteristics that are at the basis of transaction risks significantly affect the selection of trusted partners to collaborate with as well as their use of various control practices to manage relationships. We also find that in particular competence trust facilitates the use of control practices to support effective SCM.     

Uncertainty and commitment in commissioning of health services

This article reports on the use of management accounting information in commissioning of health services in England. The effects of environmental pressures and uncertainty on the use of this information in the decision-making process was examined. The relationship was further analysed from the perspective of interorganizational dependence and commitment with reference to particular financial management and budgeting practices. A more integrated approach to health care commissioning could be achieved by better harmonizing fund allocation, performance measurement and management systems and by supporting cultivation of joint multiprofessional groups so that regional hubs of information could be used to formulate consistent, bottom-up and lasting local strategies to secure inter-organizational trust and mutual dependency between local health alliances.     

A BUDGETHOLDING EXPERIMENT IN NEW ZEALAND

This paper provides a case study of a New Zealand health centre which embarked on a budgetholding (similar to UK fundholding) trial in 1992. The case study is grounded in the changes underway in the New Zealand public sector and in the management and organisation of health care. The case discusses the impact of the budgetholding trial on the practice and reflects on the future of budgetholding in New Zealand. Initial indications are that general practitioners are moving away from practice based budgetholding and are combining into Independent Practice Associations (IPAs) to facilitate contract negotiations and to provide additional leverage in dealing with secondary care providers.     

Primary Care Groups: Trade-offs in Managing Budgets and Risk

The NHS reforms introduced on 1 April 1999 were intended to remove competition and promote co-operation in the delivery of health care. This was to be achieved in part by the development of joint working by groups of General Practitioner (GP) practices covering populations of around 100,000-known as Primary Care Groups (PCGs). A key element is the integration of responsibility for managing both the clinical and financial aspects of delivering health care. The authors report on the success of this new joint role, based on findings from a national survey. There are trade-offs in choosing the scale at which to encourage GPs to take on their new roles. Smaller groups will be better able to integrate practices' clinical and financial responsibilities, while larger groups will have less financial risk due to random variation.     

Does corporate social responsibility protect shareholder value from the shock of COVID-19? Evidence from China

Our study examines whether and how increased engagement in social responsibility activities by a firm affects movements in its stock prices during the COVID-19 public health crisis, which is regarded as an exogenous shock to economic ties between focal firms and their customers, employees, and suppliers. We find that corporate social responsibility has an inverted U-shaped relationship with shareholder value. The nonlinear relationship is more dominant at firms with higher cash-flow constraints and weaker cost-adjustment capabilities. Our research also generates meaningful implications for business practices.     

Will Practice-Based Commissioning in the English NHS Resolve the Problems Experienced by GP Fundholding?

Labour's new approach to primary health care, based around the policy of practice-based commissioning, has considerable potential for learning from the general practitioner fundholding reforms put in place by the Conservative governments of the 1990s. However, practice-based commissioning seems to repeat many of the same problems as the earlier policy. Despite the increased scope for GPs to make a significant difference to the shape of local health economies because of the incentives and opportunities offered by payment by results and patient choice reforms, the potential problems of practice-based commissioning threaten the reform's viability and long-term success.     

The relationship between supplier control and competition in public sector outsourcing

The aim of this article is to develop theory and contribute to empirical studies about how the effectiveness of bureaucratic controls in public sector outsourcing is contingent upon supplier competition, and why and how this interaction plays out differently for hard and soft types of outsourced services. In previous inter‐organizational management control (IOMC) research there is a contradiction between theory and empirical results concerning how bureaucratic control and supplier competition interacts in aligning suppliers. While IOMC theory suggests competition reduces the need for bureaucratic control, empirical studies clearly indicate the opposite. We extend previous research and theorizing by differing between the outsourcing of hard and soft types of services and by testing the joint effect of bureaucratic control and competition on supplier alignment. The empirical case for testing theory is outsourcing by competitive tendering in the public sector. We use transaction level data from 166 local government suppliers in Sweden. In accordance with our prediction, the effect of bureaucratic control in aligning suppliers decreases with supplier competition when hard types of services are outsourced. For soft types of services, our results indicate that bureaucratic control is not contingent upon supplier competition. Furthermore, we show that when supplier competition is low the effect of bureaucratic control on supplier alignment is stronger for hard than for soft types of services. These results constitute an important contribution to the central notion of the interplay between bureaucratic control and competition in the IOMC literature.     

Improving Secondary Care Efficiency: Motives and Mechanisms in Scotland

Improving the efficiency of the NHS has been a consistent policy objective of British governments in recent years and the structures and mechanisms appropriate for stimulating efficiencies have led to both radical and incremental changes. This article discusses the attitudes and behaviour of fundholding and non-fundholding general practitioners (GPs) under the market system, and uses this as a basis for proposing efficiency improvements within the new health service structures in Scotland.     

Factors influencing Japanese auto suppliers’ predictions about the future of new technologies – An exploratory study of electric vehicles

This article investigates the effects of different characteristics of supplier–customer relationships in the Japanese automotive industry, and how these influence predictions about future technologies of a disruptive nature, such as Electric Vehicles (EVs). We conducted a survey of a broad set of suppliers in the Japanese automotive industry and another survey of suppliers registered with Toyota's two supplier associations. The data were used to analyse the influence of particular relationships and practices on information gathering about new technologies, preparations for R&D and production of new components, and predictions about new technologies. The study shows that suppliers’ R&D intensity and the usage degree of the drawing-supplied parts system lead to predictions favouring the uptake of new technologies. Moreover, communication between automakers and suppliers and arm's-length relationships simultaneously lead to favourable views on the future of new technologies, especially with regard to EVs. Moreover, we find that Japanese-style cooperative relationships, arm's-length relationships, communication between automakers and suppliers, and communication among suppliers all lead to less favourable views on new technology uptake (in this case, EVs). We discuss the implications of these findings for research and practice, specifically for EVs.     

How companies tackle health care costs: Part II.

In this continuing examination of responses to the growing costs of health care, based on a survey of more than 200 large companies, the author discusses the results of employers' efforts to trim these expenses. Most companies have chosen to meet the cost-cutting challenge by changing demand--that is, by redesigning their health insurance policies--and by changing the suppliers of health care services. After a critical analysis of these mechanisms, the author concludes that most of these strategies do little more than shift the costs from one payer to the next. To affect the total cost of the system, she maintains the business sector must use its power to bring about changes in the reimbursement of providers and in the underlying structure of the health care system.     

Buyer seller relationships in the UK insurance market: Is this the key competitive advantage?

In services marketing much of the recent literature recommends the use of relationship marketing frameworks rather than the extended marketing mix which adds people, process and physical evidence to the traditional four Ps of product, price, promotion and place. In the UK permanent health insurance sector some suppliers sell through intermediaries, making this an ideal environment for testing the value of relationship marketing. Using the Industrial Marketing and Purchasing (IMP) group framework, interviews were conducted with 100 intermediaries. Respondents were asked to rate their top two suppliers against five relationship marketing variables: commercial skills, technical skills, commitment, adaptability and conflict management.The data showed the top supplier was rated more highly than the second supplier in three of the criteria:— commercial skills— technical skills— adaptability.Two of the criteria, commercial skills and technical skills, showed significant differences. The results of this research provide support for the importance of relationship marketing within this sector of the insurance market. For suppliers in the insurance industry, developing competencies in adaptability and conflict management may be the best method both to differentiate the firm and to develop competitive advantage.     

Capital Investment in Primary Care—The Funding and Ownership of Primary Care Premises

The authors describe the complexity of the financing arrangements of primary care premises. They explain how the early vision of integrating health and social services within local health centres failed to be realized, with GP-owned practice premises remaining as the dominant model. There was a switch to private finance when the government loan body (General Practice Finance Corporation) was privatized in 1989. Although capital can now be freely raised by the private sector for investment in the National Health Service (NHS), these debts have to be repaid through NHS funds or user charges. The complexity, combined with demographic factors, makes it likely that as GPs opt for the Personal Medical Services (PMS) scheme and a salaried service, the trend towards for-profit corporations owning and buying out GP premises will accelerate.     

Interorganizational cost management in the exchange process

This paper explores interorganizational cost management (IOCM) practices in the exchange process. IOCM can be defined as buyers’ and suppliers’ coordinated efforts to reduce costs. Past research has primarily argued that such practices depend on component characteristics, relationship characteristics, and characteristics of the transaction. Based on a study of three buyer–supplier relationships, this article also finds variations in IOCM practices between six main activities in the exchange process. In this process, the supplier's management accounting is found to be more important than recognized by prior research. The deepest collaboration around IOCM issues and the greatest joint use of suppliers’ management accounting in the three cases typically occurs in earlier activities in the exchange process, including supplier selection, joint product design and joint manufacturing process development. In later activities in the process, during full-speed production as well as in product and manufacturing process redesign, suppliers’ managerial accounting plays a lesser role in our study.     

Assessing Benefits from Department of Health and National Health Service Research & Development

Public services in the UK are increasingly expected to account for their outputs and performance. This article describes a retrospective evaluation of the benefits from the R&D funded by a regional office of the NHS Executive. The methods adopted enabled the various elements of the region's R&D portfolio to be examined and provided a basis for the development of a plan for regular monitoring. The proposals for implementation are now also feeding into a debate as to how health services R&D might best be monitored nationally in a way that is compatible with the norms and practices of research in other contexts.