About the study

OPI has been awarded a grant 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 aims to:

• assess the impact of the NHS reforms on clinical motivations and performance
• analyse the responses of different groups of clinicians to the reforms
• explore the robustness of `donated labour’ as a proxy for professional motivation.

In particular, the study is tracing 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 is drawing on Hospital Episode Statistics (HES) data from 1994-5 to 2007-8 and on other secondary data sources. It is also obtaining primary data from interviews with up to 75 doctors and 75 nurses who are UCLH employees, including their psychometric profiles. We want to find out how their work patterns have changed for as far back as they can remember.

Check out the study poster here. 

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

Paula Palmer, OPR Psychological Resources

Anne Kilby, recently retired UCLH consultant

Progress to date (October 2008)

The team has compiled a history of reforms and organisational changes at UCLH: some 37 in all since 1975. The analysis of HES data is well underway. 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 have begun to obtain primary data.

Some preliminary 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 were organised and managed.

The working hypothesis emerging from this preliminary analysis is that supply-side changes, in activity and staff productivity, are explained by a hierarchy of factors which include:

• NHS-wide changes in strategy, funding and payment regimes
• London-wide hospital reorganisation and management
• UCLH Trust-level strategies
• Speciality management
• `Team citizenship’
• Staff characteristics

Disentangling the relative strengths of these factors on activity and staff productivity poses a significant challenge.

Papers posted

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)

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

PMETB survey of trainee doctors

Annual survey of hours and earnings