“liberating the nhs?” - birmingham.ac.uk · strategies often taken when leading processes of...

Health Services Management Centre

NewsletterVolume 16 No 2

In this issue:

A Tale of Two White Papers:comparing ‘The New NHS’ and‘Equity and Excellence’ 2

The courage to think and actdifferently 2

Decommissioning PCTs: prioritysetting in the liberated NHS 4

The freedom to flourish? 5

Altogether now – where next forhealth and social care integration? 6

Choice and control – the dilemmasof responsibility 7

Postgraduate programmes 8

Projects update 9

Events 11

People at HSMC 12

experience enforced changes. Even theDepartment of Health and national bodiessuch as the NHS Institute and NPSA facemajor re-organisation or abolishment. Thepotential involvement of private organisationsand social enterprises could lead to theindependent sector becoming a major playerin direct NHS delivery and commissioning andsignal the end of a largely public sectorservice.

In any major re-organisation there is a naturaltendency to become focussed on theoperational details of the new arrangementsand judge its success by the smoothness andpace with which new structures and workingprotocols are implemented and hurdles suchas legal challenges are overcome. GPconsortia may take over commissioning,providers may become foundation trusts andnational bodies may be disbanded but theseare not indicators of success. Successshould instead be judged by the new healthsystem’s ability to treat people in thecommunity rather than in secondary carewhenever possible, to tackle the growth inhealth inequalities, to promote health and well-being, and to ensure that health and socialcare needs are considered coherently andorganised around the circumstances andwishes of the patient. In financial terms thenew system may achieve the planned saving

“Liberating the NHS?”Editorial by Robin Miller and Russell Mannion

The absence of an overall majority and thesubsequent coalition between two partieswho had campaigned on their ideologicaldifferences could have been expected to leadto a government of compromise in whichpolicies would be watered down and lackingin radical direction. The reality to date hasbeen quite different, with major initiativesbeing introduced in key policy areas andsweeping cuts to national and regionalbodies. The National Health Service has onceagain been centre stage as a newgovernment seeks to make its mark, withAndrew Lansley’s proposals for GPcommissioning receiving particular attentionand interest within both the professionalpress and national media. The proposed scaleand pace of the changes are breathtaking,with few of the current NHS organisationsbeing unaffected – GPs, Provider Trusts,Public Health and Community Services will all

of 45% of management costs, but if this leadsto developments in community based care notbeing realised then the long-term financialcosts may outweigh these savings.‘Liberating’ NHS clinicians from the ‘control’ ofmanagers and centrally based targets isrelatively easy for the government to achieve– ensuring that the resultant ‘freedoms’ lead tomore efficient and high quality patient-centredcare will be a much harder endeavour thatwill require fundamental changes in theculture of health care organisations. In thisnewsletter HSMC provides an initial reflectionon the White Paper – this will be followed by aseries of events and more in-depth policypapers. We look forward to engaging withpolicy makers, clinicians, managers andpatients in discussing and debating the issuesthat arise and in so doing influencing thenational debate.

[email protected]@bham.ac.uk

http://www.bham.ac.uk

http://www.hsmc.bham.ac.uk

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This sectioncompares the firstNHS White Papersof the NewLabour and theConservative/Liberal-DemocratCoalitionGovernment: ‘TheNew NHS’ (NNHS)of 1997 and

‘Equity and Excellence’ (EE) of 2010respectively. While there are manyimportant differences, this analysisfocuses on the similarities….

The importance of the NHS: ‘Creatingthe NHS was the greatest act ofmodernisation ever achieved by a Labourgovernment’, with its important ‘historicprinciple’ of access based on need(NNHS), while EE claims that ‘the NHS is agreat national institution. The principles itwas founded on are as important now asthey were then’.

Devolution: ‘The needs of patients will becentral to the new system’ and ‘Localdoctors and nurses … will shape localservices.’(NNHS). Similarly, EE promisesmore control to both patients andprofessionals: ‘Healthcare will be run fromthe bottom up, with ownership anddecision-making in the hands ofprofessionals and patients.’ However,control by patients and professionals aretwo very different and incompatible

principles. For example, how can ‘choice’for homeopathy be reconciled with‘evidence-based medicine’? Bothgovernments’ ‘driving seats’ are crowdedwith back seat drivers.

‘Building’ on what has worked: NNHSclaimed that PCGs kept what worked aboutfundholding, but discarded what had failed.Similarly, EE claims to build on key aspectsof the existing arrangements: for example, anumber of GP consortia are likely to emergefrom practice-based commissioning clustersand Monitor will become the economicregulator. ‘We will learn from the past, andoffer a clear way forward for GP consortia’.

Tackling ‘Bureaucracy’ and ‘red tape’: Agreater proportion of NHS resources will goto the ‘front line’ - NNHS set out to cut £1bover the term of the Parliament, while EEwishes to find £20b in ‘efficiency savings’and cut some 45% of management costs.The costs of organisational disruptions havealways been under-estimated bygovernments, and no government has yetsucceeded in the ‘trick’ of improvingservices while cutting costs.

Reconciling quality and fairness (NNHS)and excellence and equity (EE). NNHSaimed for a ‘one-nation NHS’, with ‘fairaccess’ and the reduction of ‘unacceptablevariations’ Instruments such as NICE andNSFs did put the ‘national’ in the NHS, andreduced to some extent the post-codelottery. Apart from the vague hopes

A Tale of Two White Papers: comparing ‘The NewNHS’ and ‘Equity and Excellence’ Martin Powell

associated with the NHS CommissioningBoard and tweaking a resource allocationformula, there is little in EE that is likely todeliver greater equity. Moreover, a mainfeature associated with devolution isincreasing local responsiveness anddifferentiation rather than increasing equity.

Public health, prevention andreducing inequalities. This is not thefirst (or probably the last) time thatgovernments have promised to refocusupstream, but policy mechanisms haverarely matched the rhetoric.

Labour claims that EE represents a ‘gamble’but it is probably no more of a gamble thanNNHS. The gamble is probably more linkedwith the ‘double whammy’ of organisationalupheaval and austerity. NNHS claims that itwas a ‘ten year programme’ that wouldmodernise the NHS so that it was preparedfor the next fifty years. That turned out tobe patently false, but whether the claim ofEE that this White Paper is the long-termplan for the NHS in this Parliamentary termand beyond is accurate remains to beseen. Politicians remain convinced (despiteall the evidence) in the ‘organisational fix’,and that just one more reorganisation willget it all right. However, it might be that theNHS moves not from ‘good to great’ butrather from ‘boom to bust’.

[email protected]

The courage to think and act differentlyDeborah Davidson

As the NHS beginsa time of enormousstructural changeI would like tosuggest that thoseleading andworking with thechange in the NHSneed to think andact differently intheir approaches to

change. Grint (2005) suggested that thereare three ways in which problems can beframed:

1. Critical: a crisis, where there is little timefor discussion or dissent or worrying aboutprocedures that get in the way ofresolution. The role taken up by leaders incrises is that of Commander.

2. Tame: there are tried and testedprocedures to resolve the problem becausemanagement can, and has, previouslyexperienced the same thing happen. Inthese situations, the role taken up is that ofManagement.

3. Wicked: there are “no easy answers”(Heifetz, 1994) because the problem mightbe a new unknown situation that peopleunderstand differently, it may be embeddedin other problems which means that actions

can have consequences elsewhere thatcannot necessarily be anticipated or itmay be a dilemma that is not going to goaway and needs to be worked with. Therole taken up here is that of Leadershipand the task is to ask appropriatequestions.

Using this typology, Grint goes on tosuggest that there are (at least) two waysthat leaders frame situations.They understand the situation as objectiveand real, and concentrate on understandingthe problem and then act accordingly:

It’s Wicked so they must Lead It’s Tame so they must Manage It’s Critical so they must Command


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Alternatively they understand the situationas socially constructed and concentrateon what we do best, what resources areavailable, what might work best and how topersuade audiences:

Leadership – construct the problem asWicked

Management – construct the problem asTame

Command - Construct the problem asCritical

Grint argues that leaders and decision-makers often construct the problem tomatch their “preferred mode ofengagement, rather than what ‘the situation’apparently demands” (2005:1467).

Quinn and Sonenshein (2008) mirror Grint’sarguments when setting out the kinds ofstrategies often taken when leadingprocesses of change. They draw on thework of Chin and Benne (1969) who

suggested there were three generalstrategies for change1:

Empirical-rationale (telling): peoplewill adopt the change if it can be rationallyjustified and if it can be shown to be in theirself interests to do so;

Power-coercive (forcing): peoplechange when power is applied in someform; those with less power comply to theplans, directions and leadership of thosewith greater power; and

Normative-re-educative(participating): change in a pattern ofpractice or action will occur only as thepeople involved are brought to change theirnormative orientations to old patterns anddevelop commitments to new ones.

They added a fourth strategy:

Leadership agency (transcending):people are proactive in co-creating their

Figure 1: A typology of problems, power and authority

Source: Grint (2005:1477)

What we might take from this is that each ofthese different constructions of problemsand strategies for change are legitimate indifferent circumstances and can becombined to provide a more effectivestrategy for change.

However, the valency2 (Bion, 2000) in thepublic sector is to approach these majorchanges as either tame (Rittell and Webber,1973) ( i.e. been there, done it, got theT-shirt, or worse) or as critical. Thechallenge to those leading change in theNHS will be to avoid treating every changeas if it were life and death (a crisis)because policy implementation demandsthis, and be mindful to frame problems andselect strategies for change that areappropriate for the different challengespresented. Addressing issues as wickedand engaging patients, staff and otherstakeholders in collaborative dialogue willenable a shared view and new solutions tobe found.

[email protected]

Bion, W. (2000) Experiences in groups andother papers. London: Routledge (firstpublished in 1961)

Chin, R. and Benne, K.D. (1969) Generalstrategies for effecting changes inhuman systems, in Bennis, W.G., Benne,K. D. & Chin, R. (Eds.), The planning ofchange (32–59). New York: Holt,Rinehart & Winston.

Etzioni, A. Modern organizations. London:Prentice Hall, 1964.

Grint, K. (2005) Problems, problems,problems: the social construction ofleadership, Human Relations, 58,11,1467-1404

Heifetz, R.A. (1994) Leadership withouteasy answers. London: HarvardUniversity Press

Quinn, R. E. and Sonenshein, S. (2008) Fourstrategies of change, in Cummings, T.(Ed.), Handbook of organisationdevelopment (69-78). London: Sage

Notes1 Definitions by Jean E. Neumann on

HSMC’s MSc in Leading Public ServiceChange and Organisational Development

2 Making decision or taking actions on thebasis of assumptions, withoutconscious purpose or thought

Figure 2: Four General Strategies for changing human systems

environmentsand futures byexamining theirintegrity gaps(between whatthey say andwhat they do)and make afundamentalcommitment tobecoming morepurpose-centredand other-focussed.

Their four-foldframework isshown:

The Participating Strategy

Emphasis: relationship and open dialogue Is everyone included in an open dialogue? Do I model supportive communication? Is everyone’s position being clarified? Am I surfacing the conflicts? Are the decisions being made participatively? Are the people cohesive?

The Transcending Strategy

Emphasis: potential and transcending self Am I internally directed? Is my purpose clear? Am I other focused? Am I externally open, moving forward into uncertainty? Are the people walking with me into uncertainty?

The Forcing Strategy

Emphasis: authority and leverage Is my authority firmly established? Is the legitimacy of my directive clear? Am I able and willing to impose sanctions? Is there a clear performance-reward linkage? Am I using maximum leverage? Are the people complying?

The Telling Strategy

Emphasis: facts and rational persuasion Am I within my expertise? Have I gathered all the facts? Have I done a good analysis? Will my conclusions withstand criticism? Are my arguments clear? Are the people listening?

Interpersonal Perspective

Transformational Perspective

Possibility and Emergence Trust Vision

Compliance Logic Political

Perspective Technical

Perspective

Structure and Control

Pres

erva

tion

of

th

e Sy

stem

Exte

rnal

Alig

nmen

t of

the

Sys

tem

Source: Quinn and Sonenshein (2008:77)


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giving priority setting groups genuine powerand authority;

having strong governance structures – thisincludes aspects of performancemanagement, and the practical politicsassociated with coalition-building;

strong leadership and support from acrossthe health economy to ensure thatprioritisation decisions are implemented byproviders;

having a well-resourced knowledgeanalysis and exchange infrastructure atlocal levels;

managing the expectations of (andrelationships with) the public, clinicians,industry and government.

For some time now at HSMC we have beenengaged in the practical and theoreticalchallenges of rationing in a cold climate.Projects range from the internationalcomparisons and NHS case studies of ChrisHam, Shirley McIver, Penny Mullen andcolleagues to more recent research into PCTpriority setting and commissioning (and aforthcoming editorial in the journal PublicMoney and Management). Based on thiswork we would argue that whoever therationing task falls to will need to adopt arange of strategies. Whilst we acknowledgethe benefits of decision support analysis andframeworks for achieving fair processes ofdecision making we also consider the ‘non-decision making’ elements of priority setting tobe of crucial importance. Managing theauthorising environment and giving dueattention to the implementation of rationingdecisions are key. Of course, thesechallenges are not unique to the NHS and weare engaged in collaboration with colleagues

Decommissioning PCTs: priority setting in theliberated NHS Suzanne Robinson and Iestyn Williams

Whilst national debate continues aboutwhat GP commissioning will look like onecertainty is that the cold economic climaterequires tough decisions aroundinvestment and disinvestment. GPs areused to making individual decisions aroundpatient care, but are less experienced inmaking decisions on a population level.However, considerable time and resourcehas been committed by PCTs and otherorganisations from across health andsocial care to develop priority settingstructures and processes. Work by HSMCwhich explores commissioning and prioritysetting across England identifies someimportant lessons. For example,technocratic approaches includingProgramme Budgeting and MarginalAnalysis (PBMA) and scorecardtechniques have been used (with somesuccess) to aid priority setting. However,much of this has tended to focus onallocation of additional resources ratherthan on core spend and/or disinvestment.Where priority setting has been mostsuccessful commissioners have usedtechnical approaches but also recognisedthe importance of the non-technicalaspects of priority setting. These include:

from Europe, Australia, New Zealand, theUnited States and Canada in order to shareideas, research findings and best practicein the allocation of increasingly scarcehealth care resources.

Suzanne Robinson and Iestyn Williams areacademic leads for the commissioning andpriority setting research work at HSMC


Ham, C. and Robert, G (eds.) (2003)Reasonable rationing: internationalexperience of priority setting in healthcare. Maidenhead: Open UniversityPress, 4-16

Ham, C., McIver, S. (2000) Contesteddecisions: priority setting in the NHS.London: The King’s Fund

Robinson, S., Dickinson, H., Freeman, T.,Williams, I. ‘Disinvestment after the newWhite Paper: the challenges facing GPcommissioners’ Public Money andManagement, Forthcoming

Mullen, P. and Spurgeon, P. (2000) Prioritysetting and the public. Abingdon:Radcliffe Medical Press.


‘The freedom to flourish’? Robin Miller and Iain Snelling

With the majority of media attentionfocussing on plans for GP commissioning,the general public could be forgiven forthinking that there will be little change intheir local providers of health services. It iscertainly true that existing foundation trustswill be able to continue as organisations,enjoy greater financial freedoms and mayno longer be working to a number of thehigh profile waiting time targets (althoughthese may be maintained within localcontracts). But in reality the coalition is alsolooking for radical change in the degree ofcompetition between providers, the typesof organisations that will deliver health careand the relationship between patients andproviders.

New Labour had already started down thisroute and a number of their initiatives willbe continued by the coalition. These includemajor organisational changes such as theshedding of PCT provider services byMarch 2011 under Transforming CommunityServices, despite concerns by somePrimary Care Trust Chief Executives thatthe deadline would not allow properconsultation and could lead to the maindeterminant being what was achievable inthe timescale rather than what couldprovide long-term strategic benefits. Theright of PCT staff to request to deliver NHSservices through a social enterprise hasbeen maintained, and whilst this has hadrelatively limited take up it should lead toover 50 new enterprises being developed.This includes large enterprises delivering arange of community provision as well assmaller organisations delivering discreteservice areas. NHS Trusts will no longerexist as an organisational form and allcurrent Trusts will have to becomeFoundation Trusts within 3 years. It is notclear as yet what will happen to those whodo not meet Monitor’s requirements, but‘take over’ by a Foundation Trust or by aprivate provider may be the most likelyoptions.

Choice and competition will continue to beused as levers for change. The principle of an‘any willing provider’ approach will beextended for all elective procedures, andpatients will be able to choose any providerthat fulfils national price and qualitystandards. Competition will also be introducedfor clinical teams with their peers (through forexample the publication of quality accounts)and by patients having choice over whichconsultant team they are referred to.

Further personal health budgets pilots will beencouraged, and a possible right to apersonal budget is being considered inrelationship to discrete areas such ascontinuing health care. Outcomemeasurements related to patient reporting willbe extended and payments (and penalties)related to quality will continue.

So will this mixture of ‘carrots’ and ‘sticks’ leadto greater productivity and improved quality?There is evidence that competition betweenproviders can lead to improved quality andreduced costs, but only if there is the correctbalance of incentives and purchasers havesufficient power (Propper, 2010). Patientshave been shown to respond positively tohaving the option of choice over the provider,but their decision can be strongly influencedby the views of their GPs (who often alsohave a perception of the likely interest of thepatient in being able to make thischoice) and they do not oftenuse published information onperformance (Dixon et al 2010).

Furthermore pressure onprovider management andfinance teams will notnecessarily lead to behaviourchange in clinicians as they areoften more loyal to theirspeciality and their patients thanto their organisations and mosthave lived through numerous re-organisations.

Arguably the central issue is willthe policy changes lead to asupportive and empoweringculture in which quality iscelebrated, errors are learntfrom, patients respected andthere is a spirit of co-operationbetween clinicians andmanagers, primary andsecondary care, and health andsocial care? Developing such aculture requires sensitivity to thecorrect balance between

transactional and transformationalmanagement and a connectivity betweenBoard and frontline practice (Mannion et al,2005). The ‘mutual’ and ‘employee-owned’models being promoted for foundationtrusts and social enterprises could provideenvironments for such cultures to develop(Ellins & Ham, 2009) – we must hope thatthe need to find such large cost savingsand corresponding reduction inmanagement do not dominate the agenda tothe extent that new opportunities are lost.


Dixon, A., Robertson, R., Appelby, J., Burge,P., Devlin, N., Magee, H. (2010). Patientchoice: how patients choose and howproviders respond. London: The KingsFund

Ellins, J. & Ham, C. (2009) NHS Mutual –engaging staff and aligning incentivesto achieve higher levels ofperformance. London: The NuffieldTrust

Mannion, R., Davies, H. & Marshall, M.(2005) Culture for performance inhealth care. Buckingham: OpenUniversity Press.

Propper, C. (2010) The operation of choiceand competition in health care. London:2020 Public Services Trust.

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Altogether now – where next for health and socialintegration? Jon Glasby

As is often the case,the changes set out inthe new White Paperrepresent both anopportunity and athreat. On the ‘threat’side of the equation,the NHS is facing oneof the biggestreorganisations andone of the most

difficult financial situations in its history.This will inevitably make it a harder partnerto work with in the short-term as itsattention is naturally focused on setting upthe new system, making the requiredsavings and reducing management costsby 45 per cent. All the available evidencesuggests that reorganisations like this canreduce morale and productivity as well asstall positive service delivery – sometimesfor two years or so after the originalchanges. The tone of the White Paper isalso unhelpful in places – as many of themanagers who will be helping to introducethese changes are feeling veryunappreciated and are wondering abouttheir own jobs and futures. We also knowvery little about some of the GP consortiathat will emerge – while some will want todevelop strong relationships with socialcare, it’s possible that others may focusmore on what they might see as coreclinical business.

On the positive side, the White Paper offersan opportunity for local government moregenerally to take a greater role in promotinghealth, tackling health inequalities andensuring local democratic accountability.With its accountability national rather thanlocal, the NHS has always had anambiguous relationship with local peopleand communities, and the language ofdemocratic legitimacy in the White Paper isgenuinely exciting. Of course, there is nowa further consultation document to explorewhat this might mean in practice, and thedevil is likely to be in the detail – beingresponsible for joint working and forpromoting local accountability with veryfew mechanisms to actually deliver wouldbe the worst of all worlds, and the jury isstill out. Also promising is the scope todevelop more locality-based approaches tohealth and social care, working with GPconsortia, local services andneighbourhoods to join services up at morelocal level. This could also be boosted ifwe can find ways of making better use ofscarce public resources across agencyboundaries, rather than working inorganisational silos. Probably most

revolutionary of all is thecontinued development ofpersonal health budgets,which could enable peoplewith complex and multipleneeds to join up their owncare and support from thebottom up in a way thatmakes sense to them.

What is crucial is that thecurrent focus on systemsand structures doesn’t get inthe way of the softeraspects of partnership andintegration. Whateverstructures emerge andhowever they work, the keyissues are often to do withpersonal relationships,professional values andculture. This requiressignificant attention to thehuman aspects of jointworking and a firmcommitment to organisationaldevelopment, to staffengagement and to serviceuser and patient involvement.

In the current financial andpolitical climate, moreover,the challenge is not to find ways of doingmore of the same for less, but to morefundamentally rethink the whole nature ofwhat we do. This will require us to engagewith local communities much morefundamentally than in the past about thenature and the quality of the health and socialservices that people want and need. In thepast we have often tried to promote jointworking through the power of ideas (tellingpeople it’s a good idea to work together) orthrough changing structures, and theevidence suggests that this hasn’t worked. Alot of the White Paper is about starting tochange incentives, and this can be apowerful mechanism. However, some of theWhite Paper might also be about changing theunderlying accountabilities – between thestate and the individual, between the NHS andlocal government, and between services andlocal people. If we could find an approachwhere the accountabilities, incentives,structures and ideas were all aligned, thenwe might really start to make a difference.

[email protected]

An HSMC policy paper, All in thistogether? Making best use of healthand social care resources in an era ofausterity, will be available shortly viathe HSMC website(www.hsmc.bham.ac.uk)


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The focus on patient choice, shareddecision making, personalised care, patientrating of care, and strengthening thecollective voice of patients and the public,all suggest a continuation of pre-existingpolicy. The drawback is it also means thecurrent government is likely to face thedilemmas inherent in this direction of traveltowards greater patient responsibility forhealth. These dilemmas are particularlyapparent at the level of the individual, whichis the focus here, but there are similarimplications for the collective patient voiceand public involvement which will bementioned at the end and which will beexamined further in a HSMC Policy Paper tobe published early next year.

Increased patient choiceThe White Paper makes it clear that theGovernment intends to travel both furtherand faster down the road to greater choiceand control, but what evidence is there thatpatients want greater choice and/or controlover treatment and care decisions?Research suggests that while there aresome circumstances in which somepatients want choice and control, there areother situations where patients wouldprefer not to have choice or control but willaccept it because they are reluctant tocause trouble.

Auerbach (2001:192) clarified thebehavioural rationale for why people wantto be involved in healthcare as “a desire toimpose active control over a situation withpotentially aversive consequences”. Hedrew attention to a useful distinctionbetween three major ways in which peoplecan exercise control:

Cognitive (informational) control – toreduce ambiguity and uncertainty

Decisional control – to identifypreferences for different choices

Behavioural control – to be involved intreatment implementation

Choice and control – the dilemmas of responsibility

The evidence suggests that while patientsacross many health care settings desiredetailed information about their condition andtreatment, they are less likely to want to makedecisions about their care. They are only likelyto want control if they feel it will improve theoutcome or help avoid an aversive outcome.

A study reported by Taylor, Hall and Salmonin 1996 illustrates Auerbach’s findings andpoints to some of the current dilemmas inassessing and measuring patient desire forcontrol, and for staff involved in implementingpolicy relating to control. Taylor andcolleagues (1996) examined the finding thatpatient controlled analgesia (PCA) results ingreater patient satisfaction compared withtraditional analgesic regimes even though thisproduces a relatively small and variableimprovement in analgesia - the assumptionbeing that improved satisfaction reflectspatients’ preference to have control over theirpain relief.

The researchers carried out interviews withpatients after they had received PCAfollowing surgery. They found that not onlywere negative experiences relating toineffectiveness and side effects such asnausea reported, but also only one patient outof the 26 interviewed reported the controlprovided by PCA as one of the benefits. Themajority saw it as better than the alternativewhich was delay due to nurses beingunavailable. PCA was a way of avoiding theembarrassment of showing distress andseeking help from the ‘busy’ nurses.

When control is disempoweringSimilar complex and mixed evidence can befound in studies examining patients’experiences of self-management and copingwith chronic conditions. This has led somewriters to suggest that this type ofempowerment is a way of transferringresponsibility from the health professional tothe patient in situations that are difficult for thehealth professional (e.g. Salmon and Hall,2004). This evidence suggests that whilstmoves towards better information should beas fast as possible, a more cautiousapproach should be taken towards greaterpatient control and responsibility, because insome situations it may bring responsibilitywithout the power to prevent unwantedeffects, such as poor quality care, sufferingand death - a situation which isdisempowering.

So what is the relationship betweenincreasing individual control andstrengthening the collective patient andpublic voice? The answer again is the riskthat responsibility will be transferred insituations where control is eitherimpossible, unwanted or not given. Thefact that for the third time in ten years themechanism for collective voice is to bedismantled and reformed into a neworganisation (Health Watch) is open toseveral interpretations ranging fromconspiratorial (to keep the collective voicefrom becoming organised) to pragmatic (tokeep pace with changing health policy andstructures).

Luckily there are sources of evidence thatcan inform this debate and help in the goalof strengthening collective voice. These liein the experiences of other countries whichhave structures representing the patientand public voice as well as in the UKexperience of CHCs, Patients’ Forums andLINks. HSMC will be examining these,carrying out a number of focus groupdiscussions with health professionals aboutPPI, and reporting our findings in the nearfuture.


Auerbach, S. (2001) Do patients wantcontrol over their own health care? Areview of measures, findings andresearch issues, Journal of HealthPsychology, 6(2),191-203

Department of Health (2010) Equity andexcellence: liberating the NHS. London:TSO

Salmon, P. and Hall, G. (2004) Patientempowerment or the emperor’s newclothes, Journal of the Royal Society ofMedicine, 97:53-56

Taylor, N., Hall, G., Salmon, P. (1996) Ispatient controlled analgesia controlled bythe patient? Social Science andMedicine, 43(7),1137-1143

Jo Ellins and Shirley McIver


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Postgraduate programmes

MSc in HealthcareCommissioningNHS West Midlands andCommissioning Support London haveseparately commissioned HSMC todeliver MSc programmes in HealthcareCommissioning. Run part-time overtwo years, the programmes aim toprovide a comprehensive singlecourse that helps to develop thecompetencies that health and socialcare commissioners require in an eraof world class GP-led commissioning,and to support the ongoingdevelopment and professionalisationof the commissioning function. Inparticular, the programmes explore:

The policy context and politicalenvironment in which strategiccommissioning has become a coreelement of public servicemanagement;

How commissioning andprocurement have emerged in thecontext of wider public sectorreform and modernisation, and howthey are likely to develop in thefuture;

Key theoretical models underpinningstrategic management andprocurement in the public sector;

Different approaches to decisionmaking and priority-setting in theallocation of public resources, andtheir strengths and limitations;

The different reasons for andapproaches to involving the public instrategic commissioning activities,and the evidence regarding theimpact of such involvement.

For further details contact

[email protected]

HSMC Graduates celebrating their successat the Summer 2010 Graduation

the general management programme willalso be joined by six Medical Leaders fromthe North West deanery and for the firsttime, six Clinical Fellows.

New Alumni Website LaunchedAll alumni from the three leadershipprogrammes run by the NHS Institute forInnovation and Improvement – the GraduateManagement Training Scheme, BreakingThrough and Gateway to Leadership –now have access to an exclusive website:www.institute.nhs.uk/alumni

Launched mid-September, alumni whoregister on the site can create their ownpersonal profile, access news and eventspages, join a discussion forum, and searchfor people, organisations and projects thatmight be of interest. As John Boileau andRebecca Ball, who have been instrumentalin getting the site live, say: “The websiteprovides fantastic networking opportunitiesand is monitored daily to ensure that youare receiving relevant and up to dateinformation. If you know anyone who hascompleted any of the programmes pleasespread the word, as the more people whojoin the alumni website the greater thebenefits.”

If you have any queries or suggestionsplease do not hesitate to contact John orRebecca at [email protected]

NHS Graduate Management TrainingScheme – update and new alumniwebsiteIn 2007 HSMC was chosen (followingcompetitive tender) to lead the provision of theeducational component of the NHS GraduateManagement Training Scheme (MTS) for thethird time in a row - the first time this hashappened in the Scheme’s 50 years history.The current provision is a partnershipbetween HSMC, University of Birmingham andManchester Business School, University ofManchester. The training scheme, managedby the NHS Institute for Innovation andImprovement, is a leadership and developmentprogramme for trainees in England. In 2010

HSMC delivers a number of UK-basedMasters programmes as well ascontributing to a number ofinterdepartmental programmes. Theseinclude:

1. MSc in Health Care Policy andManagement, with an option tospecialise in:- Quality and Service Improvement,

or- Commissioning

2. MSc in Leadership for Health ServicesImprovement

3. MSc in Public Service Commissioning(with the Institute of LocalGovernment).

4. MSc in Managing Partnerships inHealth and Social Care (with theInstitute of Local Government)

5. Leading Public Service Change andOrganisational Development

All of HSMC’s Masters programmesemphasise the application of theoreticalperspectives to current policy andpractice in the NHS and other health caresystems, and are explicitly designed tosupport professional as well asacademic development. The majority ofour students study part-time (over 2years) whilst working in the healthservice or a related field, although we dohave a number of full-time studentsstudying on our UK-based programmes,and completing their qualification within12 months.

HSMC staff bring their wide knowledgeof UK and international health systems(gained through research andconsultancy activities, as well as theirown professional experience) to theirteaching and tutorial support forstudents. This emphasis is maintainedthroughout all of our programmes, fromthe choice of titles for assignments,through the involvement of practitionersand policy makers in teaching activities,to the topics selected for dissertations.While some students choose toconcentrate on theoretical topics, manystudents carry out empirical studies fortheir dissertation, often related to theirown place of work or area ofprofessional expertise.

For further details of this or any of theabove programmes, please contactKate Vos, 0121 414 3174

[email protected]


HSMC - Newletter 9

Projects Update

A Beveridge Report for the 21st Century

At the end of June, HSMC was the venue fora two-day think tank entitled ‘A BeveridgeReport for the 21st Century’, organised by JonGlasby and Catherine Needham from HSMCand Simon Duffy from the Centre for WelfareReform. The event was funded by theAdvanced Social Sciences Collaborative atthe University of Birmingham. With a smallinvited audience of leading policy makers,managers, practitioners, policy analysts andresearchers, the think tank sought to explorethe implications of personalisation and self-directed support for: local government,children’s services, the NHS, criminal justiceand the tax and benefit systems. Participantsconsidered whether a new Beveridge Reportor process is needed to clarify thinking andoptions around the relationship between thestate and the individual in the twenty-firstcentury. Papers from the conference will bepublished later this year by the Centre forWelfare Reform/HSMC.

Contact: [email protected]

Aspiring Director Programme

HSMC is continuing to lead the developmentand delivery of the Aspiring Directorprogramme commissioned by NHS WestMidlands. The 44 participants on cohortsseven and eight begin their four moduleprogramme in October 2010 and will completein May 2011. The programme includes severalthemes which are proving challenging anduseful to participants in their current roles aswell as preparing them for future changes.Evaluations of previous programmes say thatthe short Organisational Consultancyexperience which takes place in non-NHSorganisations such as Wolverhampton CAB,the New Vic Theatre in Newcastle-uder-Lymeand Birmingham Airport, has been particularlyvaluable.


European modelling of long-term care

HSMC make a continuing contribution toINTERLINKS, an EU study into long-term carefor older people in 14 European countries.Recent activities have involved HSMC as co-ordinators of a work package focused on thegovernance and finance of long-term care.National reports from 11 European countriesfeed into an overview report on contextualfactors that influence sustainable goodpractice in LTC systems. The report, due to befinalised at the end of the year, considers theoverlap between preventive approaches,informal care and ensuring quality from afinance and governance perspective. DetailedEuropean overview reports on these three

areas have also been produced by theINTERLINKS consortium and are available atthe project websitewww.euro.centre.org/interlinks


New Project on medical tourism

Russell Mannion was co-applicant withcolleagues at the University of York and theLondon School of Hygiene and TropicalMedicine on a two year NIHR Health ServicesResearch programme funded projectexploring the policy implications of inward andoutward medical tourism. The study will seekto identify the number of overseas patientsvisiting the UK each year for the purposes ofaccessing medical care as well as thenumber of self funded UK patients travellingoverseas for treatment. It will also explore thequality and safety of services provided tomedical tourists and provide an estimate ofthe economic costs to the NHS.


Priority setting: an exploratory study ofEnglish PCTs

Priority setting in health and social carecontinues to be a difficult task with toughchoices around resource allocation needed tobe made. Staff at HSMC are currentlyconducting a study which explores prioritysetting across English PCTs. The study mapsout the different types of priority settingactivities which are currently taking placewithin PCTs, and provides an in-depthinvestigation into the experiences andperceptions of those involved. This work isfunded by the Nuffield Trust and results willbe reported in the autumn. Dissemination willinvolve publications and a national eventwhich will include representatives from anumber of commissioning organisations aswell as policy makers and other experts fromthe arena of priority setting. If you would likemore details on the forthcoming publicationsor the national event then please contactSuzanne Robinson.


Feasibility study into the transfer ofcommissioning of forensic serviceexaminations for sexual offences

The outcome of this study is to help theDepartment of Health and ministers reach adecision on where best to locateresponsibility for commissioning forensicmedical services for sexual offences, and toprovide evidence to support serviceimprovement in local delivery.

There is currently great variation in howforensic medical services are provided inrape and sexual assault cases in the UK, andthere is little consistency between policeforces in terms of how services arecommissioned and medical examinersemployed. Key issues are the availability of a24 hour service, the need for more femaleforensics examiners (preferred by bothfemale and male victims) and the provision offollow-up health services around infectionand STDs.

Currently commissioning responsibility andbudgets are held by the Police, but following anumber of reviews, it has been recommendedthat this responsibility is transferred to theNHS. A key challenge will be to ensure thatthe feasibility study not only takes account ofthe economic considerations, but mostimportantly the case for change in relation tovictims’ experiences of services.


Talent management in the NHS

Professor Martin Powell is leading a multi-centre NIHR SDO funded research project intoTalent Management in the NHS in England. Co-collaborators include colleagues from theUniversity of Surrey and Royal Holloway,University of London. The two-year project,due to complete at the end of February 2011,has involved a literature review, focusgroups, and detailed interviews with nationalexperts and leadership/talent managementleads at the ten SHAs. The project is in theprocess of completing a national survey ofNHS managers and detailed interviews with60 managers throughout England, and iscurrently setting up data collection on talentmanagement at what have been defined as‘five high performing trusts’, beforeconcluding with a second focus group.Further details can be obtained from Phil Moss(project Research Fellow):

[email protected]

High impact changes in older people’sservices

HSMC have produced a review of emergingevidence around prevention in older people’sservices. The paper builds on HSMC’songoing contributions around prevention andrehabilitation within long-term care as part ofan EU research project. The work identifiesand reviews ten high impact changes,addressing the acknowledged need to embedprevention into older people’s services. HSMCwill present their findings at Healthy Agingevents at the King’s Fund and the InternationalCentre for Life later this year.



10 HSMC - Newletter

Projects Update continued

HSMC contributes to report onincentives and performance in primarycare

HSMC’s Professor Russell Mannion is part ofthe team that has recently published a reporton the impact of incentives on primary care.The team, led by Professor Ruth McDonaldfrom the University of Nottingham, wasfunded by the National Institute for HealthResearch (NIHR) Service Delivery andOrganisation Programme to undertake a threeyear study investigating the impact of a rangeof incentives on primary care professionals’behaviour and performance.


The report can be downloaded from the SDOwww.sdo.nihr.ac.uk/projdetails.php?ref=08-1618-158

Joint commissioning in health andsocial care commissioning

HSMC is involved in research to explore theimpact of joint commissioning on serviceusers. This 2 year SDO funded project seeksto explore the processes, practices andoutcomes of joint commissioning in health andsocial care, across 8 case study sites inEngland. So far sites 5 out of 8 have beenrecruited involving 2 Care Trusts; 2 Health andWellbeing partnerships and a ‘ConnectedCare’ project. The project team are currentlyin phase 1 of the research which involves aunique on-line survey, specifically designedaround Q Methodology. This analysesparticipant attitudes to a series of outcomestatements based around joint commissioning.This data will be supplemented by theexperiences of service users in phase 2.The project team, led by Jon Glasby, involvesHelen Dickinson and Alyson Nicholds fromHSMC and Stephen Jeffares and HelenSullivan from the School of Government andSociety.


Leicestershire County and RutlandCommunity Healthcare Services

HSMC and Leicestershire County and RutlandCommunity Health Services are currentlyinvolved in a research and developmentpartnership programme, to build theinfrastructure, skills and capacity of theprovider, to become a research anddevelopment based organisation. The overallpurpose is to improve patient care, transformcommunity services and embed a culture oflearning from evidence within theorganisation.

A number of planned activities have been on-going since last autumn including:

Establishing five multi-disciplinary researchand development groups linked to theTransforming Community Services agenda;

An annual programme of days to developprimary research skills;

Four seminars, focussing on the applicationof evidence into practice;

Eight half day masterclasses to front-lineservices and teams on topics/foci of theirchoice linked to Research into Practice;

Developing a research and developmentportal to support staff learning aboutresearch and development;

Establishing an organisational developmentTask Force to support the embedding of aresearch and development culture; and

Undertaking a multi-level evaluation lookingat outcomes from the programme.

The research projects are well underway anddue to present some of the findings at a finalnational event on 23 November at theLeicester Racecourse and ConferenceCentre.


Evaluating the impact of the SocialEnterprise Investment Fund: progressto date

An HSMC evaluation team has beencommissioned by the Department of HealthPolicy Research Programme to assess theeffectiveness of the Social EnterpriseInvestment Fund in supporting socialenterprise entry into health and social care.The research comprises three phases whichbroadly run sequentially over the two yearperiod from July 2009-June 2011. ‘Phase One’(July 2009 to January 2010) of our researchinterviewed policy makers and other actorsinvolved in formulating the SEIF in order tounderstand the ‘programme theory’. Both thePhase One report and an extendedstakeholder analysis will shortly be availableon the TSRC/HSMC website.

‘Phase Two’ (February 2010 to September2010) of our research undertook a survey ofall the social enterprises that weresuccessful and unsuccessful in receivingSEIF investment. A Phase Two report will besubmitted to the Department of Health laterthis month and will then be available on theTSRC/HSMC website.

We will shortly be starting Phase Three of ourresearch (October 2010 to June 2011) whichwill be carrying out in depth case studies ofsuccessful and unsuccessful SEIForganisations.

Contact: [email protected] [email protected]

Older people and care transitions

The second stage of an SDO fundedresearch project examining the experiencesof older people undergoing transitions incare has begun. During this stage 80 olderpeople in Manchester, Leicester, Solihull andGloucestershire will be interviewed by aresearcher accompanied by a trainedservice user co-researcher. The interviewwill include questions about theirexperiences at different stages of theirtransition, what would have made it easierand what messages they would like to sendto care providers. The project also includesan analysis of the literature, follow upinterviews after a six month interval, anddevelopment work with the case study siteslinked to the dissemination of findings.


Responding to the White Paper

HSMC has been asked to address a rangeof local, regional and national organisationson the implications of the 2010 White Paperand related topics, including the LocalGovernment Association, the National SkillsAcademy for Social Care, the Social CareAssociation and the National Association ofPrimary Care.


Personalisation in learning disabilityservices

HSMC have been commissioned by aprovider of services for people with alearning disability to evaluate their supportfor people with complex needs and identifyhow well placed they are to provide‘personalised support’ for people living inresidential care homes.Contact: [email protected] [email protected]


HSMC - Newletter 11

Events

Biennial Conference in Organisational Behaviour in Health Care

HSMC hosted the prestigious 7th BiennialConference in Organisational Behaviour inHealth Care (OBHC) from the 11th to 14thApril. The theme of the conference, whichattracted over 150 academics andpractitioners from across the globe, was‘Mind the Gap: policy and practice in thereform of healthcare’. Visiting academicswere invited to share their expertise, andpresent and discuss papers that exploredthe behaviours of healthcare organisationsin shaping, adapting and resistingdevelopments in healthcare policy andpractice.

In addition to the academic programme,delegates also had the opportunity to tourthe Barber Institute of Fine Arts, theUniversity’s own renowned art gallery, andhad dinner at Birmingham Council House,

preceded by a private viewing of theStaffordshire Hoard - an exciting, newlydiscovered treasure trove of Anglo-Saxonartefacts.

The academic conference wascomplemented by a one-day practitionerseminar attended by senior NHS managersand clinicians, who took the opportunity todiscuss the conference theme withacademics. Over the course of the eventHSMC were delighted to welcome threedistinguished Keynote speakers: Dr PeterHupe from Erasmus University, Rotterdam;Ben Page, from Ipsos MORI and ProfessorMichael West from Aston Business School.

Here are just a few of the many commentsfrom attendees:

“It has been the highlight of my conferenceyear” – academic from University ofSouthampton

“An excellent conference. The organisationwas first class and the kindness andhelpfulness of everyone made it special.The programme had really good qualitypapers and the overall content was well-structured” – academic from Aberdeen

“I very much enjoyed it, and really lovedBirmingham” – research officer – Canada

“How fab I thought the conference was. Itwas really superb - we have a lot to live upto. I was particularly impressed by yourteam and how positive they were” –academic from Dublin and hosts for nextconference in 2012

“On behalf of the Executive and Trustees ofSHOC I am writing to thank you for a veryenjoyable 2010 conference in Birmingham.

Ben Page, Chief Executive of IPSOS Mori,

keynote speaker on the 3rd day of the

Conference

The liberation of NHS Commissioning: how will we cope with freedom?

Wednesday 24 November 2010

HSMC is holding a seminar entitled ‘The liberation of NHS Commissioning: how will we cope withfreedom?’ The aim of the workshop is to provide an opportunity for participants to feel that theyare fully au fait with current policy, share their views with their peers and be able to considerwhat support would be helpful over forthcoming months. Keynote speakers include: David ColinThomé and David Martin, both of whom have been involved in the planning and delivery of localand central policy for a number of years, and Judith Smith, policy analyst from the Nuffield Trust,who will share her expertise and views on the current reforms. The seminar is aimed at seniorNHS leaders involved in commissioning including: PCT CEOs, Directors of Public Health andsenior GP commissioners.

The non-residential registration fee is £150 with a reduction of 25% for representatives ofvoluntary sector organisations.

To book a place please contact Ann Thomas on 0121 414 7058, email: [email protected] further information contact Suzanne Robinson on 0121 414 3011,email: [email protected]

The Conference was held in the lecture room in

the University of Birmingham Business School

We were particularly pleased with boththe streaming of papers and theopportunities to meet old and newfriends within such interesting locationsand with such delightful catering.Birmingham has made a lastingimpression on us all” – Chair of SHOC



People at HSMC

Maximizing the value of England’s NHS:What is the role of the public? (SophieDavis Medical School, New York)

Implementing rationing decisions in healthcare (Vancouver Coastal Health Authority,Canada)

Organising for innovation in health care:strategies and approaches (Centre forHealth Care Management, UBC)

A number of joint-papers and research bidsare currently underway between Iestyn andcolleagues from the Centre for Health andClinical Epidemiology (UBC, Canada) andCommunity Health and Social Medicine (CUNY,New York).

University recognisesProfessor’s policycontributionProfessor Jon Glasby haswon the University’s CharlesBeale award for influencing

national policy. Jon was presented with hisaward at the annual Vice-Chancellor’s dinnerby Michael Collie from BBC Midlands Today.

The prestigious award is granted to anacademic who is judged to have made asignificant contribution to policy debate, in thiscase, the White Paper on long-term care forolder people, issued in March 2010. Jon wasrecognised for his report, The case forsocial care reform – the wider economic andsocial benefits, which concludes that withouta radical rethink of current priorities, the realcost of providing social care will double in thenext twenty years.

Building on this work, Jon andHSMC colleagues continue toexert their influence and informongoing policy debates in thisarena with the current coalitiongovernment.

Jon has also been appointed as a Non-Executive Director of Birmingham Children’sHospital, having previously served as theUniversity’s representative on the Council ofGovernors.

12 HSMC - Newletter

A formal researchcollaboration has been set upbetween HSMC and the

Australian Institute for Health Innovation (AIHI)and the Centre for Clinical GovernanceResearch at the University of New SouthWales (UNSW), Sydney, with the purpose ofdeveloping a joint portfolio of research in thearea of health care quality and patient safety.As part of the collaboration RussellMannion has been made a Visiting Professorat UNSW and Jeffrey Braithwaite, director ofAIHU has been appointed to a similar post atHSMC (see below). UNSW is a leadinginternational centre for health systemsresearch and is consistently ranked amongthe top 50 universities in the world.

Professor JeffreyBraithwaite who is currentlyProfessor and FoundationDirector of the AustralianInstitute of Health Innovationand Professor and Director of

the Centre for Clinical Governance ResearchFaculty of Medicine, University of New SouthWales, Australia has recently joined HSMC asHonorary Professor. Professor Braithwaite isa leading health services organizationalresearcher with an international reputation forhis work in health systems improvement,particularly investigating the culture andstructure of acute settings, leadership,management and change in health sectororganizations, quality and safety in healthcare, accreditation and surveying processesin international context and the restructuringof health services. He is well known forbringing management and leadershipconcepts and evidence into the clinical arenaand he has published extensively (more than400 total publications) about organizational,social and team approaches to care whichhas raised the importance of theseinternationally.

Academic study tourupdateSince July of this year, IestynWilliams has been in NorthAmerica writing up researchfor publication and making links

with colleagues from the University of BritishColumbia (Vancouver) and City University ofNew York. As part of this he has deliveredthe following seminars:

Prestigious national awardfor HSMC LecturerHSMC Lecturer HelenDickinson has won the ‘bestnewcomers’ award at thisyear’s Social Policy

Association (SPA) conference. Helen waspresented with her award by Nick Timminsfrom the Financial Times and President of theSPA, at the annual conference dinner.The prestigious and hotly contested award isgranted to a lecturer/researcher who isjudged to have made a significant earlycontribution to the field of social policy interms of research, publications and teaching.Her selection was based on 3 areas ofoutstanding achievement:-

1. Helen’s extensive and impressivepublications record. She has co-authored7 books and 20 articles in (mostly) refereedjournals. In addition, she has contributed tonumerous research reports and practitionerjournals. Her publications record is trulyoutstanding for such a new researcher.

2. Her record in securing external researchincome and her developing researchleadership role. As principal investigator,Helen has secured nearly £200K externalresearch funding. She also leads thehealth and social care component of theservice delivery research stream for theESRC Third Sector Research Centre.

3. Helen’s teaching and administration roles.As well as being recently appointed asHSMC’s Director of Teaching, Helen isresponsible for several HSMC MSc modulestargeted at practitioners and managers.She also led the organisation for theinternational conference in OrganisationalBehaviour in Health Care, which was heldin April.

Of her achievement, Helen said, “I’m incrediblyproud of this award though I don’t considerthis to be a solo effort - rather, it is atestament to the support I’ve received at theHealth Service and Management Centre in theSchool of Social Policy. Being an early careerresearcher can be challenging, but I guess I’mreally lucky. I’m in a Department and a Schoolthat is really supportive, and there’ssomething about early career researcherssupporting each other that has been reallyhelpful. You can’t underestimate theimportance of networking.”

Some sad newsHSMC were saddened to hear of the sudden death of Dave Doyle from Knowsley Council/NHS Knowsley. Dave has worked with HSMC onvarious projects over the last decade and was a tireless champion of integrated working. HSMC are very grateful for all his contributions toour work and send our condolences to Dave’s family and colleagues.

Collaboration with theAustralian Institute forHealth Innovation


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