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Biomedical subjects

Russell Mannion

Publications and source records attributed to Russell Mannion.

At least 19 recordsLinked to original sources
PubMed2006

Decentralising the NHS: rhetoric, reality and paradox.

PURPOSE: The purpose of this research is to examine the issues of decentralisation in the NHS. DESIGN/METHODOLOGY/APPROACH: Evidence was gathered from an empirical study in order to illustrate the effect of policy reform on relationships at both the central and the local level. In this paper issues were examined in the context of two reforms at the heart of the decentralisation agenda in the English NHS: earned autonomy and the introduction of foundation hospitals. FINDINGS: Past and current policy in the NHS reflects elements of both centralisation and decentralisation. The tension created by such opposing forces has an impact not only on inter-organisational partnership working but also on the balance of power within local health economies. ORIGINALITY/VALUE: Attempts to control the NHS exhibit unresolved contradictions and tensions. This research showed that the challenge for policymakers, managers and clinicians is to manage such tensions.

Empirical Research↗
PubMed2006

Q methodology in health economics.

The recognition that health economists need to understand the meaning of data if they are to adequately understand research findings which challenge conventional economic theory has led to the growth of qualitative modes of enquiry in health economics. The use of qualitative methods of exploration and description alongside quantitative techniques gives rise to a number of epistemological, ontological and methodological challenges: difficulties in accounting for subjectivity in choices, the need for rigour and transparency in method, and problems of disciplinary acceptability to health economists. Q methodology is introduced as a means of overcoming some of these challenges. We argue that Q offers a means of exploring subjectivity, beliefs and values while retaining the transparency, rigour and mathematical underpinnings of quantitative techniques. The various stages of Q methodological enquiry are outlined alongside potential areas of application in health economics, before discussing the strengths and limitations of the approach. We conclude that Q methodology is a useful addition to economists' methodological armoury and one that merits further consideration and evaluation in the study of health services.

Data Interpretation, Statistical↗
PubMed2005

A hermeneutic science: health economics and Habermas.

PURPOSE: Mainstream health economics labours under a misleading understanding of the nature of the topic area and suffers from a concomitant poverty of thinking about theory and method. The purpose here is to explore this critical position and argue that health economics should aspire to being more than a technical discipline. It can, and should, engage with transformative discourse. DESIGN/METHODOLOGY/APPROACH: It is argued that the hermeneutic sciences, emphasising interpretation not instrumentality or domination, offer a route into the change to which one seeks to contribute. The article specifically focuses on the way Habermas provides insights in his approach to knowledge, reason and political economy. How he emphasises complexity and interaction within cultural milieu is explored and primacy is given to preserving the life-world against the encroachments of a narrow rationalization. FINDINGS: The argument for a critical re-imagining of health economics is presented in three stages. First, the antecedents, current assumptions and critical voices from contemporary economics and health economics are reviewed. Second, the way in which health is best understood via engaging with the complexity of both the subject itself and the society and culture within which it is embedded is explored. Third, the contribution that hermeneutics, and Habermas' critical theory, could make to a new health economics is examined. ORIGINALITY/VALUE: The paper offers a radical alternative to health economics. It explores the shortcomings of current thinking and argues an optimistic position. Progress via reason is possible if one reframes both in the direction of communication and in the appreciation of reflexivity and communality. This is a position that resonates with many who challenge prevailing paradigms, in economics and elsewhere.

Economics, Medical↗
PubMed2005

Alternative futures for health economics: implications for nursing management.

As nursing has been subject to successive waves of 'managerialism' there has been a drive on the part of government and elements within the profession to enhance the science base and promote cost-effective health care interventions. This has generated new interest in the 'economics of nursing' as efficiency and 'value for money' are viewed as necessary precondition for the provision of a high quality nursing service. As an academic subject health economics has brought an elegant set of theories to bear on the topic of health and health care. However, mainstream health economics is premised on a series of simplifying assumptions that, if applied uncritically, can induce a range of unintended and adverse consequences. This paper asks how ideas developed in one sphere (health economics) can be become influential in another (nursing management and practice) and it seeks explanations in the theories of Michel Foucault, specifically in his exploration of the reciprocal relationship between power and knowledge. How are our assumptions about what is possible and desirable shaped, how far do mechanisms of surveillance and self-subjugation extend? A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. Some of these are better suited to the complex social environment present within health care. Nurses, nurse managers and researchers should question the assumptions of dominant economic models and explore a range of economic frameworks when planning services and evaluating their practice.

Attitude to Health↗
PubMed2005

Impact of star performance ratings in English acute hospital trusts.

OBJECTIVE: To explore some of the impacts of star performance ratings in acute hospital trusts in England. METHODS: A multiple case study design was used which incorporated purposeful sampling of 'low' and 'high' performing trusts using the star rating system. In each case study site, data collection comprised semi-structured interviews and documentary analysis. Between eight and 12 senior managers and senior clinicians were interviewed in each organisation. RESULTS: There was a general view that the star ratings as presently constituted did not represent a rounded or balanced scorecard of their own organisation's performance and a widespread belief that the information used to calculate the ratings was often incomplete and inaccurate. The star ratings were viewed by some managers as useful, in that they gave added weight to their trust's modernisation agenda. In addition to driving beneficial change, the ratings were also sometimes reported to have inadvertently induced a range of unintended and dysfunctional consequences, including tunnel vision and a distortion of clinical priorities, bullying and intimidation, erosion of public trust and reduced staff morale, and ghettoisation. CONCLUSIONS: Set in the context of an international body of research, this study highlights some important gaps in knowledge and failings in current policy and practice. In particular, the many dysfunctional consequences of publishing star ratings indicate a need for a re-examination of performance management policies.

Efficiency, Organizational↗
PubMed2005

Decentralization strategies and provider incentives in healthcare: evidence from the english national health service.

INTRODUCTION: This article examines the incentive effects of delegating operational and financial decision making from central government to local healthcare providers. It addresses the economic consequences of a contemporary policy initiative in the English National Health Service (NHS)-earned autonomy. This policy entails awarding operational autonomy to 'front-line' organisations that are assessed to be meeting national performance targets. In doing so, it introduces new types of incentives into the healthcare system, changes the nature of established agency relationships and represents a novel approach to performance management. METHODS: Theoretical elements of a principal-agent model are used to examine the impact of decentralization in the context of the results of an empirical study that elicited the perceptions of senior hospital managers regarding the incentive effects of earned autonomy. A multi-method approach was adopted. In order to capture the breadth of policy impact, we conducted a national postal questionnaire survey of all Chief Executives in acute-care hospital Trusts in England (n = 173). To provide added depth and richness to our understanding of the impact and incentive effects of earned autonomy at an organisational level, we interviewed senior managers in a purposeful sample of eight acute-care hospital Trusts. RESULTS: This theoretical framework and our empirical work suggest that some aspects of the earned autonomy as currently implemented in the NHS serve to weaken the potential incentive effect of decentralization. In particular, the nature of the freedoms is such that many senior managers do not view autonomy as a particularly valuable prize. This suggests that incentives associated with the policy will be insufficiently powerful to motivate providers to deliver better performance. We also found that principal commitment may be a problem in the NHS. Some hospital managers reported that they already enjoyed a large degree of autonomy, regardless of their current performance ratings. We also found evidence that the objectives of providers may differ from those of both the central government and local purchasers. There is, therefore, a risk that granting greater autonomy will allow providers to pursue their own objectives which, whilst not self-serving, may still jeopardize the achievement of strategic goals. CONCLUSION: It is apparent that the design and implementation features of decentralizing policies such as earned autonomy require careful attention if an optimal balance is to be struck between central oversight and local autonomy in the delivery of healthcare.

Hospitals, Public↗
PubMed2003

Managing change in the culture of general practice: qualitative case studies in primary care trusts.

OBJECTIVES: To explore the potential tension between the need for managers to produce measurable change and the skills required to produce cultural change, and to investigate how managers of primary care trusts are attempting to deal with this tension. DESIGN: Qualitative case studies using data derived from semistructured interviews and a review of published documents. An established cultural framework was to used to help interpret the findings. SETTING: Six primary care trusts in England purposefully sampled to represent a range of cultural, structural, geographical, and demographic characteristics. PARTICIPANTS: 42 interviews with 39 different senior and middle primary care trust managers conducted over an 18 month period. RESULTS: We found two distinct and polarised styles of management. One group of managers adopts a directive style and challenges the prevailing norms and values of clinicians, an approach characteristically seen in organisations with hierarchical cultures. This group is made up mostly of senior managers who are driven principally by the imperative to deliver a political agenda. Managers in the second group are more inclined to work with the prevailing cultures found in general practice, attempting to facilitate change from within rather than forcing change from outside. This management style is characteristically seen in organisations with a clan-type culture. The approach was manifest mostly by middle managers, who seem to act as buffers between the demands of senior managers and their own perception of the ability and willingness of health professionals to cope with change. The different management approaches can lead to tension and dysfunction between tiers of management. CONCLUSIONS: The development of primary care depends on high quality managers who are able to draw on a range of different management skills and styles. Managers are most likely to be effective if they appreciate the merits and drawbacks of their different styles and are willing to work in partnership.

Administrative Personnel↗
PubMed2003

Public disclosure of comparative clinical performance data: lessons from the Scottish experience.

There is growing international interest in making information available on the clinical quality and performance of health care providers. In the United States of America, where public reporting is most advanced, comparative performance information in the form of 'report cards', 'provider profiles' and 'consumer reports' has been published for over a decade. In Europe, Scotland has been at the forefront of releasing clinical performance data and has disseminated such information since 1994. This paper reviews the Scottish experience of public disclosure and distils the key lessons for other countries seeking to implement similar programmes. It is based on the findings of the first empirical evaluation of a national clinical reporting initiative outside the United States. The study examined the impact of publication of Scottish (CRAG) clinical outcome indicators on four key stakeholder groups: health care providers, regional government health care purchasers, general practitioners and consumer advocacy agencies. We conclude that those responsible for developing clinical reporting systems should not only pay close attention to developing technically valid and professionally credible data which are tailored to the information needs of different end users, but should also focus on developing a suitable incentive structure and organizational environment that fosters the constructive use of such information.

Breast Neoplasms↗
PubMed2003

Implementing culture change in health care: theory and practice.

OBJECTIVES: To review some of the key debates relating to the nature of organizational culture and culture change care organizations and systems. METHODS: A literature review was conducted that covered both theoretical contributions and published studies of the processes and outcomes of culture change programmes across a range of health and non-health care settings. RESULTS: There is little consensus among scholars over the precise meaning of organizational culture. Competing claims exist concerning whether organizational cultures are capable of being shaped by external manipulation to beneficial effect. A range of culture change models has been developed. A number of underlying factors that commonly attenuate culture change programmes can be identified. Key factors that appear to impede culture change across a range of sectors include: inadequate or inappropriate leadership; constraints imposed by external stakeholders and professional allegiances; perceived lack of ownership; and subcultural diversity within health care organizations and systems. CONCLUSIONS: Managing organizational culture is increasingly viewed as an essential part of health system reform. To transform the culture of a whole health system such as the UK National Health Service would be a complex, multi-level, and uncertain process, comprising a range of interlocking strategies and supporting tactics unfolding over a period of years.

Health Care Reform↗
PubMed2003

The quantitative measurement of organizational culture in health care: a review of the available instruments.

OBJECTIVE: To review the quantitative instruments available to health service researchers who want to measure culture and cultural change. DATA SOURCES: A literature search was conducted using Medline, Cinahl, Helmis, Psychlit, Dhdata, and the database of the King's Fund in London for articles published up to June 2001, using the phrase "organizational culture." In addition, all citations and the gray literature were reviewed and advice was sought from experts in the field to identify instruments not found on the electronic databases. The search focused on instruments used to quantify culture with a track record, or potential for use, in health care settings. DATA EXTRACTION: For each instrument we examined the cultural dimensions addressed, the number of items for each questionnaire, the measurement scale adopted, examples of studies that had used the tool, the scientific properties of the instrument, and its strengths and limitations. PRINCIPAL FINDINGS: Thirteen instruments were found that satisfied our inclusion criteria, of which nine have a track record in studies involving health care organizations. The instruments varied considerably in terms of their grounding in theory, format, length, scope, and scientific properties. CONCLUSIONS: A range of instruments with differing characteristics are available to researchers interested in organizational culture, all of which have limitations in terms of their scope, ease of use, or scientific properties. The choice of instrument should be determined by how organizational culture is conceptualized by the research team, the purpose of the investigation, intended use of the results, and availability of resources.

Health Services Research↗
PubMed2003

Does organisational culture influence health care performance? A review of the evidence.

OBJECTIVE: To review the evidence for a relationship between organisational culture and health care performance. METHODS: Qualitative comprehensive review: all empirical studies exploring a relationship between organisational culture (broadly defined) and health care performance (broadly defined) were identified by a comprehensive search of the literature. Study methods and results were analysed qualitatively to provide a narrative review with integrative discussion. RESULTS: Ten studies met the inclusion criteria. There was considerable variation in the design, study setting, quality of reporting and aspects of culture/performance considered. Four of the ten studies reviewed in detail claimed to have uncovered supportive evidence for the hypothesis that culture and performance are linked. All the other studies failed to find a link, though none provided strong evidence against the hypothesis. CONCLUSIONS: There is some evidence to suggest that organisational culture may be a relevant factor in health care performance, yet articulating the nature of that relationship proves difficult. Simple relationships such as 'strong culture leads to good performance' are not supported by this review. Instead, the evidence suggests a more contingent relationship, in that those aspects of performance valued within different cultures may be enhanced within organisations that exhibit those cultural traits. A striking finding is the difficulty in defining and operationalising both 'culture' and 'performance' as variables that are conceptually and practically distinct. Considerably greater methodological ingenuity will be required to unravel the relationship(s) between organisational culture(s) and performance(s). Current policy prescriptions, which seek service improvements through cultural transformation, are in need of a more secure evidential base.

Efficiency, Organizational↗
PubMed2002

Reporting health care performance: learning from the past, prospects for the future.

In the USA, where public reporting of data on clinical performance is most advanced, comparative performance information, in the form of 'report cards', 'provider profiles' and 'physician profiling', has been published for over a decade. Many other countries are now following a similar route and are seeking to develop comparative data on health care performance. Notwithstanding the idiosyncratic nature of US health care, and the implications this has for the generalizability of findings from the USA to other countries, it is pertinent to ask what other countries can learn from the US experience. Based on a series of structured interviews with leading experts on the US health system, this article draws out the key lessons for other countries as they develop similar policies in this area. This paper highlights three concerns that have dominated the development of adequate measures in the USA, and that require consideration when developing similar schemes elsewhere. Firstly, the need to develop indicators with sound metric properties - high in validity and meaningfulness, and appropriately risk-adjusted. Secondly, the need to involve all stakeholders in the design of indicators, and a requirement that those measures be adapted to different audiences. Thirdly, a need to understand the needs of end users and to engage with them in partnerships to increase the attention paid to measurement. This study concludes that the greatest challenge is posed by the desire to make comparative performance data more influential in leveraging performance improvement. Simply collecting, processing, analysing and disseminating comparative data is an enormous logistical and resource-intensive task, yet it is insufficient. Any national strategy emphasizing comparative data must grapple with how to engage the serious attention of those individuals and organizations to whom change is to be delivered.

Data Collection↗
PubMed2002

Complexity and clinical governance: using the insights to develop the strategy.

There is increasing interest in complexity as an explanatory model to help understand how health care organisations operate and change. In this article, we present a brief introduction to some of the basic ideas in complexity and illustrate how these might be relevant to the process of implementing clinical governance. The implementation of clinical governance can be seen as a complex adaptive system: as such, we must accept that uncertainty and unpredictability are inescapable. This makes life uncomfortable for managers, but an understanding of how complex adaptive systems work helps us explore a range or management styles and practices, depending on how the 'system'--in this case the implementation of clinical govenance--is developing.

Medical Audit↗