Comparative case studies of health reform in England Report submitted to the Department of Health Policy Research Programme (PRP) Martin Powell, Ross Millar, Abeda Mulla, Hilary Brown, Chris Fewtrell Health Services Management Centre, University of Birmingham Hugh McLeod Health Economics Unit, University of Birmingham Nick Goodwin, Anna Dixon and Chris Naylor The King’s Fund Contents Executive Summary ............................................................................................... 7 Aims and objectives ............................................................................................... 7 Methods and analysis ............................................................................................ 7 Results .................................................................................................................... 8 Conclusions .......................................................................................................... 10 Chapter 1: Introduction ........................................................................................ 13 1.1 Presenting the ‘Next Steps’ policy agenda .................................................... 13 1.2 Looking inside the ‘black box’: evaluating complex policy interventions ..... 16 1.3 Plan of investigation ...................................................................................... 17 1.4 Structure of report ........................................................................................ 18 Chapter 2: Theory and Methods ........................................................................... 20 2.1 Introduction ................................................................................................... 20 2.2 Study Design ....................................................................................................... 24 2.2.1 A profile of the six case study sites ........................................................ 27 2.2.2 Case study characteristics ...................................................................... 27 2.3 Qualitative Data Analysis .............................................................................. 34 2.3.1 Content Analysis of Key Documents ...................................................... 34 2.3.2 Interviews with high-level stakeholders ................................................ 35 2.3.3 Case Study Interviews ............................................................................ 35 2.4 Quantitative data analysis ............................................................................. 36 2.5 Data Analysis ................................................................................................. 39 2.6 Methodological challenges ........................................................................... 39 Chapter 3: Policy and Literature Review ............................................................... 41 3.1 Policy Review ................................................................................................. 41 3.2 Programme Theory ....................................................................................... 43 3.2.1 The New NHS (DH 1997) ........................................................................ 43 3.2.2 NHS Plan (DH 2000) ............................................................................... 45 3.2.3 Delivering the NHS Plan (DH 2002a) ...................................................... 48 3.2.4 NHS Improvement Plan (DH 2004) ........................................................ 50 3.2.5 Our Health, Our Care, Our Say (DH 2006a) ............................................ 53 3.2.6 High Quality Care for All (DH 2008) ....................................................... 56 3.2.7 From Good to Great (DH 2009) .............................................................. 58 3.3 Literature Review .......................................................................................... 63 Demand Side Reform ............................................................................................... 63 3.3.1 Choice and Voice .................................................................................... 63 3.3.2 Primary Care Trust (PCT) commissioning ............................................... 67 3.3.3 Practice-based commissioning .............................................................. 69 Supply-Side Reform .................................................................................................. 71 3.4.1 Provider plurality ................................................................................... 71 3.4.2 Foundation Trust (FT) ............................................................................. 73 Transactional Reforms ............................................................................................. 76 1 3.5.1 Payment by Results ..................................................................................... 76 3.5.2 Quality and Outcomes Framework ............................................................. 78 3.6 System Management and Regulation ................................................................ 79 3.6.1 Targets......................................................................................................... 80 3.7 Combined impact of policy reforms .............................................................. 81 3.8 Conclusion ..................................................................................................... 84 Chapter 4: insights into the reforms from the perspective of policymakers ........... 86 Introduction ......................................................................................................... 86 4.1 Evolution of system reform ............................................................................... 86 4.2 The contribution of specific reform mechanisms ......................................... 89 4.2.1 Demand Side .......................................................................................... 89 4.2.2 Supply Side ............................................................................................. 93 4.2.3 Transactional .......................................................................................... 94 4.2.4 System Management & Regulation ....................................................... 95 4.3 Outcomes of system reforms ........................................................................ 96 4.3.1 Impact .................................................................................................... 98 4.4 Tracer conditions ......................................................................................... 100 4.5 Balance ........................................................................................................ 102 4.5.1 Next Steps to Next Stage ..................................................................... 103 4.6 Conclusion ................................................................................................... 105 Chapter 5: system perspectives on the impact of ‘Next Steps Reforms’ ............... 107 Introduction ....................................................................................................... 107 5.1 Demand Side ............................................................................................... 107 5.1.1 Choice ................................................................................................... 107 5.1.2 Voice ..................................................................................................... 109 5.1.3 Commissioning ..................................................................................... 111 5.1.4 Practice Based Commissioning ............................................................ 114 5.2 Supply Side .................................................................................................. 118 5.2.1 Diverse providers ................................................................................. 118 5.2.2 ISTCs ..................................................................................................... 119 5.2.3 FT Status ............................................................................................... 121 5.2.4 Workforce ............................................................................................ 123 5.3 Transactional ............................................................................................... 126 5.3.1 Payment by Results .............................................................................. 126 5.3.2 Management Information ................................................................... 131 5.4 System Management and Regulation ......................................................... 131 5.5 Darzi – Next Stage Review ........................................................................... 133 5.6 System updates: reform in a cold climate? ................................................. 135 5.6.1 ‘Lean Times’ ......................................................................................... 135 5.6.2 Quality and Safety ................................................................................ 140 5.7 Examining the reforms as combined Levers ............................................... 142 5.7.1 Targets and outcomes ......................................................................... 142 5.7.2 ‘Mutually supporting’? ........................................................................