A sociology of public responses to hospital change and closure

Efficiency effects of public hospital closures in the context of public hospital reform: a multistep efficiency analysis

In the wake of hospital reforms introduced in 2011 in Turkey, public hospitals were grouped into associations with joint management and some shared operational and administrative functions, similar in some ways to hospital trusts in the English National Health Service. Reorganization of public hospitals effect hospital and market area characteristics and existence of hospitals. The objective of this study is to examine the effect of closure on competitive hospital performances. Using administrative data from Turkish Public Hospital Statistical Yearbooks for the years 2005 to 2007 and 2014 to 2017, we conducted a three-step efficiency analysis by incorporating data envelopment analysis (DEA) and propensity score matching techniques, followed by a difference-in-differences (DiD) regression. First, we used bootstrapped DEA to calculate the efficiency scores of hospitals that were located near hospitals that had been closed. Second, we used nearest neighbour propensity score matching to form control groups and ensure that any differences between these and the intervention groups could be attributed to being near a hospital that had closed rather than differences in hospital and market area characteristics. Lastly, we employed DiD regression analysis to explore whether being near a closed hospital had an impact on the efficiency of the surviving hospitals while considering the effect of the 2011 hospital reform policies. To shed light on a potential time lag between hospital closure and changes in efficiency, we used various periods for comparison. Our results suggest that the efficiency of public hospitals in Turkey increased in hospitals that were located near hospitals that closed in Turkey from 2011. Hospital closure improves the efficiency of competitive hospitals under hospital market reforms. Future studies may wish to examine the efficiency effects of government and private sector collaboration on competition in the hospital market.

A matter of (good) faith? Understanding the interplay of power and the moral agency of managers in healthcare service reconfiguration

Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency - specifically their commitment to patient care - in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs.

The media's coverage and framing of hospital reforms: The case of Denmark

The Danish hospital landscape has been continuously restructured since the early 2000s. A structural reform reorganized the public sector, and a hospital reform restructured the hospital landscape, closing hospitals and concentrating specialized treatment in so-called super-hospitals. Reforms can generate considerable debate, including in the media, especially regarding sensitive topics like healthcare. The present study explores the media's coverage of the hospital reform, the antecedent structural reform, and three events related to differences in treatment outcomes, whose importance was pointed out in expert interviews. The coverage is analyzed regarding quantity and main theme (agenda-setting): tone and whether the focus was on single events (episodic framing) or broader context (thematic framing). We used a systematic keyword search to identify relevant news stories and analyzed the headlines and lead paragraphs of 1192 news stories. The three events generated a large amount of coverage, but some events varied in terms of context and tone of coverage. Further, the media covered hospital closures in connection with the two reforms differently in context and tone, although the first difference is not statistically different. Overall, the coverage of the events might have helped raise the public's awareness of challenges in the healthcare system, which could have contributed to opening a window of opportunity for a hospital reform.

The role of professional elites in healthcare governance: Exploring the work of the medical director

Medical leaders occupy a prominent position in healthcare policy in many countries, both in terms of the governance of quality and safety within healthcare organisations, and in broader system-wide governance. There is evidence that having doctors on hospital boards is associated with higher quality services. What is not known is how they have this effect. Analysing data collected from observations, interviews and documents from 15 healthcare providers in England (2014–2019), we elaborate the role of medical directors in healthcare governance as ‘translation work’, ‘diplomatic work’, and ‘repair work’. Our study highlights the often enduring emotional effects of repeated structural changes to clinical services. It also contributes to theories of professional restratification, showing the work of medical directors as regional ‘political elites’, and as ‘corporate elites’ in publicly-funded healthcare systems.

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Medical Directors affect quality through translation, diplomatic, and repair work.

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Medical Directors are regional ‘political elites’ on the frontstage and backstage.

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Some Medical Directors are ‘corporate elites’ aligned with organisational interests.

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Service change has enduring emotional effects that can negatively affect quality.

Social movements and the contested institutional identity of the hospital

Taking popular protest as a common reaction to changes in hospital services as its point of departure, this paper explores how a social movement has taken on the issue of the hospital as an institution. In the wake of the transformation of Norwegian public hospitals into health enterprises (trusts), this paper explores community resistance to the proposals and plans of decision-makers to restructure hospitals. The study is based on a qualitative and quantitative analysis of the website/blog for the local hospital movement's activities from 2007 until 2017 and of its involvement and resistance in respect of three instances of proposed change to the hospital structure during this period. The study reveals that the health enterprises and the managerialism they represent pose a threat to individual safety and sense of belonging, and to the preservation and identity of the local community. Moreover, the framing of the cause of the local hospital movement illuminates how the institutional identity of the hospital is highly contested between the institutional categories of 'public administration' on the one hand, and 'the company' on the other. The impact of the local hospital movement has proven modest in terms of influencing and reversing decisions to restructure hospitals, but it has been considerable in terms of cultural support for its concepts and values, not just concerning hospitals and health care services, but also with regard to democratic governance.

Awareness and opinions on healthcare decommissioning in a Swedish region

Decision-makers may have to decommission services as a response to budget deficits. The aim of this study was to investigate a case of decommissioning with regard to the public's awareness and opinions. The analysis of a survey in a Swedish region that begun the implementation of an extensive decommissioning programme in 2015 shows that the majority of respondents were well or very well informed about the programme (68 %). A large proportion of the respondents thought the decision-makers to a low or very low degree had adopted appropriate measures to solve the economic problems (43 %), but together more respondents were either indifferent (39.5 %) or positive (17.5 %). Regarding the level of satisfaction with the region's healthcare system, compared to prior to the decommissioning period, 30 % were less satisfied while together more were either indifferent (48 %) or had become more satisfied (22 %). The large share of indifferent responses opens up for various interpretations or framings of the programme outcomes. Trust in the regions' healthcare system nevertheless increased during the same period. Furthermore, self-assessed health as well as age and utilization seem to be associated with healthcare system satisfaction during decommissioning. This illustrates heterogeneity in the public's responses to decommissioning, which calls for further investigation.

Legitimating complementary therapies in the NHS: Campaigning, care and epistemic labour

Questions of legitimacy loom large in debates about the funding and regulation of complementary and alternative medicine (CAM) in contemporary health systems. CAM’s growth in popularity is often portrayed as a potential clash between clinical, state and scientific legitimacies and legitimacy derived from the broader public. CAM’s ‘publics’, however, are often backgrounded in studies of the legitimacy of CAM and present only as a barometer of the legitimating efforts of others. This article foregrounds the epistemic work of one public’s effort to legitimate CAM within the UK’s National Health Service: the campaign to ‘save’ Glasgow’s Centre for Integrative Care (CIC). Campaigners skilfully intertwined ‘experiential’ knowledge of the value of CIC care with ‘credentialed’ knowledge regarding best clinical and managerial practice. They did so in ways that were pragmatic as well as purist, reformist as well as oppositional. We argue for legitimation as negotiated practice over legitimacy as a stable state, and as labour borne by various publics as they insert themselves into matrices of knowledge production and decision-making within wider health care governance.

The problems of smaller, rural and remote hospitals: Separating facts from fiction

Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems - cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.