Is there scope for mixed markets in the provision of hospital care?

'Two sides of the same coin'? A longitudinal analysis evaluating whether financial austerity accelerated NHS privatisation in England 2013-2020

Objectives

To understand the relationship between increasing privatisation of the NHS and austerity cuts to public funding.

Design

Longitudinal analysis.

Setting

170 Clinical Commissioning Groups (CCGs) in England between 2013 and 2020.

Intervention

The UK austerity programme, spearheaded by the conservative-led governments of the 2010s, leveraged the 2008 financial crisis to roll-back spending to local government and social security spending. They also restricted the rate of growth in NHS spending-but cuts varied for different areas, often impacting deprived areas hardest.

Main outcome

For-profit outsourcing by NHS commissioners. After the implementation of the 2012 Health and Social Care act commissioners were encouraged and obliged to open contracts to the private sector. The uptake of for-profit outsourcing varied massively. Some CCGs contracted out almost half of their activity, and others almost none.

Results

We calculate the size of austerity across all CCGs. The financial restrictions meant that commissioners had, on average, £21.2 m more debt by 2021 than in 2014 in real terms. We find that there is a null and very small effect of changes to local NHS funding on for-profit outsourcing. A decrease in £100 per capita of NHS funding corresponds in a decrease in 0.441 percentage points (95% CI -0.240 to 1.121) of for-profit expenditure. We also find that local changes to public expenditure on the NHS, local government and social security do not confound the relationship between for-profit outsourcing and treatable mortality rates.

Conclusions

NHS privatisation at the local level does not appear to be a direct response to or result of austerity. That does not mean that it is unproblematic. Rather than being confounded by funding levels, the deteriorating health outcomes associated with privatisation should be considered as a distinct concern to the disastrous health effects of austerity policies.

Does competition support integrated care to improve quality?

Introduction

This work investigates the compatibility of integrated care and competition in China and analyses the impact of integrated care on regional care quality (DeptQ) within a competitive framework.

Method

The study was built on multivariate correspondence analysis and a two-way fixed-effects model. The data were collected from Xiamen's Big Data Application Open Platform and represent nine specialised departments that regularly performed inter-institutional referrals between 2016 and 2019.

Results

First, care quality for referred patients (ReferQ) and the relative scale of referred patients (ReferScale) and competition have an antagonistic but not completely mutually exclusive relationship. Second, ReferQ and competition both have a significant effect on DeptQ, but only when competition is weak can ReferQ and competition act synergistically on DeptQ. When competition is fierce, competition will weaken the impact of ReferQ on DeptQ.

Conclusion

Changes in the intensity of integrated care and competition ultimately affect care quality.

What is the mind map of the hospital's future changes in a developing country like Iran? A qualitative study

BACKGROUND

Hospitals have a vital role in the future of health systems with upcoming structure, resources, and process changes. Identifying the potential aspects of change helps managers proactively approach them, use the opportunities, and avoid threats. This study presents a mind map of future changes in Iranian hospitals to develop a base for further related studies or prepare evidence for interventions and future-related decisions.

METHODS

This study is a qualitative-exploratory one, conducted in two phases. In the first phase, in-depth and semi-structured interviews were conducted to identify future hospital changes over 15 years. The interviews were analyzed using the content analysis method and MAXQDA 2018 software and holding two expert panels to develop the mind map using the 2016 Visio software.

RESULTS

In the first phase, 33 interviews led to 144 change patterns. In the second phase, a mind map of changes was drawn according to experts' opinions with ten categories: structure and role, knowledge management and research, service delivery, health forces, political and legal, economic, demographic and disease, technological, and values and philosophy, and environmental.

CONCLUSIONS

Many changes affecting hospitals rooted in the past continue to the future, but the point is the increasing intensity and speed of changes. Healthcare systems need a systematic approach to monitoring the environment to be updated, agile and proactive. These monitoring systems are essential in providing evidence for Macro-level decision-makers.

Resilient managed competition during pandemics: lessons from the Italian experience during COVID-19

In the last decades, several European health systems have abandoned their vertically integrated health care in favour of some form of managed competition (MC), either in a centralised or decentralised format. However, during a pandemic, MC may put health systems under additional strain as they are designed to follow some form of 'organisational self-interest', and hence face reduced incentives for both provider coordination (e.g. temporary hospital close down, change in the case-mix), and information sharing. We illustrate our argument using evidence for the Covid-19 pandemic outbreak in Italy during March and April 2020, which calls for the development of 'coordination mechanisms' at times of a health emergency.