Markets or professionalism: Lessons from two devolved health

care systems in the UK.

C O'Donnell et al

Devolution in the NHS.

England.

Retained purchaser-provider split.

Primary Care Trusts (PCTs) commission services for their population, but also provide services.

Practice-based commissioning.

Policy drive towards waiting times; greater access; patient choice; Connecting for Health.

Some policies targeting health inequalities.

Scotland.

Integrated Health Boards.

Primary care delivery devolved to Community Health Partnerships (CHPs).

Policy drive towards chronic care; integrated care; health inequalities; waiting times; greater access; anticipatory care.

Some policies targeting health inequalities.

Devolved structures.

Greer’s “four way bet”

EnglandFocus on managerialism.

Incentives, goals and structures set

centrally but local managers autonomous

Central control over managers > over professionals

ScotlandFocus on professionalism.

No purchaser-provider split; no practice-based commissioning.

Reduced role of managers, and power

returned to professionals.

Greer, BMJ 2008: 337; a2616.

General Medical Services contract.

UK-wide contract.

Patients registered with general/family practices not with individual GPs.

Core services delivered within practices.

Enhanced services: may be delivered in general practices or by other providers.

GP opt-out from out-of-hours responsibility: now PCT/Health Board responsibility.

Greater emphasis on incentivised care.

Quality and Outcomes Framework.

Defining governance.

“… ways in which organisations and the people working in them relate to each other…”

Davies et al, SDO Scoping Report 2005.

“… the arrangements by which authority and function are allocated and rights and obligations are established and regulated and through which policies and practices are effected.”

Gray, Chapter 1 In Governing Medicine: Theory & Practice, 2004.

Models of governance.

Market driven

Professionally driven

Study overview.

Practices.

Monitoring both external (PCT/Health Board) and internal (by colleagues).

Monitoring focused on QOF in both countries through structured series of performance monitoring visits.

In England: wider use of other managerial, monitoring mechanisms including balanced scorecards.

Emphasis in both countries on supportive mechanisms of governance, rather than “harder” mechanisms.

No evidence of punitive measures, other than some withholding of QOF monies for short periods.

Enhanced services.

Little monitoring beyond “activity”, particularly in Scotland.

Some movement in England towards service specifications for practices.

More performance monitoring for the community based teams in the enhanced services.

In England, recognition that de-commissioning may occur in the future if service specifications not met.

Out-of-hours service.

In England, provided by a contracted organisation, independent of the PCT.

In Scotland, part of the Health Board.

Performance monitoring more stringent and more highly organised in England than in Scotland.

In England, very clear recognition that de-commissioning may occur in the future if service specifications not met.

Awareness of competition from other providers in England.

Professionally driven

Market driven

Conclusions.

PCTs/Health Boards central to primary care governance.

PCTs/Health Boards have adopted a professionally-led, supportive approach to raising practice performance.

Evidence supports the notion of a blended approach to governance, where no one mode of governance dominates.

Market-driven governance most evident for out-of-hours services.

Some evidence to suggest that England is more managerial than Scotland; Scotland’s “professionalism” likely a result of population size.

The GMS impact team.

University of Glasgow.

Dr Kate O’Donnell, Dr Gary McLean, Dr Suzanne Grant, Ms Michelle McKelvie, Professor Frances Mair & Professor Graham Watt, General Practice & Primary Care.

University of Dundee.

Dr Bruce Guthrie, Tayside Centre for General Practice.

University of Manchester.

Professor Matt Sutton, NCPCRD; Professor Caroline Carlisle, School of Nursing, Midwifery & Social Work.

University of Aberdeen.

Mr David Heaney, Centre for Rural Health.

University of Liverpool.

Dr Adele Ring & Dr Mark Gabbay, Division of Primary Care.