| Regulation, motivations and the NHS reforms | ||
About the study OPI was awarded a grant in 2008 by the General Medical Council under the ESRC Public Services Programme to study the interactions between formal and informal regulatory institutions on clinicians’ behaviour using the University College London Hospital NHS Foundation Trust (UCLH) as a test-bed. The study...
In particular, the study traced the effects of changes in policy and management on clinical activity and staff motivations and their productivity in order to explore whether the introduction of more formal regulations under the NHS reforms have reinforced or undermined the informal institutions of trust, ethic, professional reputation and altruism. The study has drawn on Hospital Episode Statistics (HES) data from 1994-5 to 2007-8 and on other secondary data sources. It has also obtained primary data from interviews with 46 doctors and 48 nurses from UCLH, including their psychometric profiles. We have explored how their work patterns have changed for as far back as they can remember. |
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The project team Tim Ensor, OPI Research Fellow, Principal Investigator Clare Leaver, The Queen’s College, Oxford Roger Hay, OPI Director Martin Karlsson, Oxford Institute of Ageing Anne Kilby, recently retired UCLH consultant Jerrett Myers, OPI Research Coordinator |
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Project summary The team has compiled a history of reforms and organisational changes at UCLH: some 37 in all since 1975. The analysis of HES data has ben completed . The team has now met the Clinical Directors and Divisional Senior Nurses from Directorates that account for 90 per cent of the clinical activity at UCLH. Meetings with individual doctors and nurses to obtain primary data have been completed. The data allowed proxies for `intrinsic incentives’ to be compared with reported work patterns across the sample and over time. Proxies for `extrinsic incentives’ (pay, employment regulation, management regime and `team citizenship’) were also assembled. Both types of measure were compared with clinical activity and productivity measures. Two working papers have been prepared: on the overall changes in activity and productivity at the level of the Trust; and on the effects of the reform on the working patterns of doctors and nurses. |
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Some results Substantial changes occurred during the period 1994-95 to 2006-07, both NHS-wide and within the Trust. The number of finished consultant episodes (FCEs) at UCLH grew from 30,831 to 78,553 (154%). However, there were marked differences in activity trajectories between specialities. These differences are also to be found in FCEs per consultant and in waiting times. These differences are yet to be fully explained but may reflect changes in case mix, the number of available beds, changes in technology (measured by day case-FCE ratios), changes in quality (which we have not been able to capture) and changes in demand - as well as changes in the way different specialities are organised and managed. The working hypothesis emerging from this analysis is that changes in activity and staff productivity are explained by a hierarchy of factors which include:
Disentangling the relative strengths of these factors on activity and staff productivity poses a significant challenge. Nevertheless, the tentative survey results suggest that although a stronger management regime may have reduced ‘knightly’ doctors’ motivation to work additional hours outside their contracts, a stricter management regime may have increased the level of effort by others. Significantly, despite the overall reduction in the number of hours doctors worked, overall productivity, as reflected in finished consultant episodes per consultant, has increased since 2004. It is possible that a more nuanced management regime might achieve even greater productivity by preserving the effort of `knights’ but also mobilising the effort of `knaves.’ Although these conclusions must remain tentative for the moment, they merit further investigation. More here. |
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Papers posted Management reforms and performance in a London Teaching Hospital (PDF) Tim Ensor et al, OPI The NHS reforms at the University College London Hospital Roger Hay et al, OPI (PDF) The economics of 'public service motivation': a literature review (PDF) Martin Karlsson, Oxford Institute of Ageing `Public service motivation' and performance incentives: a literature review (PDF) Jerrett Myers, OPI |
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Additional resources
The English NHS reforms have attracted considerable international interest. This page contains a selection of links and references related to the theory underpinning them and the ways successive UK governments have implemented them. NHS Hospital Episode Statistics |
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