A visit to Beijing’s Third Hospital

by Ross Millar, Lecturer at the Health Services Management Centre, University of Birmingham. 

China is a bit of a hot topic at the moment. This is no more so than the reform of its healthcare system with a variety of perspectives being put forward about the successes and missed opportunities associated with the progress made to date[1][2].

Over the past few years a group of us at HSMC have been increasingly interested in the Chinese experience, particularly in how some of its policy proposals have translated across a diverse, dynamic and increasingly powerful society. Building on previous HSMC visits, I secured some funding from the British Academy to go with Robin Miller and Russell Mannion to visit colleagues at the Peking University Health Science Centre in Beijing. The aim was to explore the possibility of developing further links between the centres with a variety meetings and seminars being held to exchange views about the key issues both systems were currently facing.

In addition, a key part of our recent visit was to gain insight into how the Chinese system worked. I suggested this to colleagues at Peking and they proposed that a visit to the local hospital might be a good idea. We gladly accepted this offer and following our first meeting we were taken to their university hospital – the Third Hospital – by two health policy and management MSc students.

As with our local hospital – University Hospitals Birmingham Foundation Trust – the Third Hospital was only a short walk from the campus. As we walked towards the back entrance of the hospital my initial reaction was fairly underwhelming. In many ways it looked like a fairly run of the mill 1970s/1980s district general hospital building we have here. Yet as we got closer this impression started to change. When I turned the corner and approached the front entrance I began to see something different: a modern hospital covered with large panes of glass and a rolling electronic screen above the entrance – a bit like those rolling signs giving the latest market figures you see on Wall Street.


We went inside and I was impressed – Robin suggested that it felt like the entrance to a train station. I agreed, it did resemble something like Grand Central station but I thought there was something else – it felt more commercial, something like the entrance to a shopping mall with its large tiled floor, elevators, and information points.

When walking through the Third Hospital it felt calm and relatively quiet. Compared to the well documented pressures on NHS hospital services this was some achievement! However our student guides were quick to inform us that the hospital was not usually like this. If we visited the hospital in the morning (rather than 3pm) we would see something quite different – long queues, high demand and the day to day chaos of a university hospital! In what felt quite similar to our experience in the NHS, our guides described how escalating hospital demand and the struggle to move care into primary and community settings were the key issues currently being faced.

The Third Hospital was two years old and this was probably the key thing that struck me more than anything e3Rosslse – it was modern and appeared relatively advanced. I was intrigued that on visiting the entrance to A&E there was equipment for patients to carry out their own blood pressure test with the results being automatically sent to the relevant parts of the hospital. I was also impressed with the amount of information and signposting for patients. Either side of the entrance were standard reception points but what also struck me was the number of standalone information booths. They looked a bit like the machines you see at job centres but these did a lot more than be mere directories. The machines provided access to patient records (password protected), further information about particular conditions, and opportunities to order and arrange prescriptions. In addition to the booths, plasma screens were dotted around on pretty much every pillar with information and updates popping up regularly.

Overall, our visit to the Third Hospital was a real privilege. I never actually found out why it was called the Third Hospital but the visit did leave me with a number of questions about the NHS – particularly how we could further facilitate patient self-management and improve the information we provide for both patients and the public. I am truly grateful to our student guides and to the Peking Health Sciences Centre.




[1] http://www.birmingham.ac.uk/Documents/college-social-sciences/social-policy/HSMC/publications/Newsletters/newsletter-volume19-no2.pdf


[2] http://www.birmingham.ac.uk/schools/social-policy/departments/health-services-management-centre/news/viewpoint/2014/china-crisis.aspx



Any views expressed in this blog are the author’s own and not necessarily those of HSMC or University of Birmingham. © HSMC 2014


DrHTDIn our latest Viewpoint piece Dr Helen Tucker, Vice President of the Community Hospitals Association discusses the role of small hospitals in the NHS.

The statement from Simon Stevens about the role of small hospitals in the NHS is welcome, and unexpected (1).

Those communities who are actively campaigning to keep their valued local hospitals are stopped in their tracks. Can this be right – does the NHS have room now for community hospitals as part of its infrastructure?  A clear message from the CEO of the NHS would suggest so.

The reason for establishing cottage hospitals originally is still pertinent – to create a clean and safe environment so that GPs, consultant specialists and nurses can work together in an integrated way to treat patients within their own communities.  It is hard to imagine that within 30 years of the first cottage being converted to create a hospital setting, there were 240 new hospitals across England (2).  This was an astounding development, possible only with public support and donations. This strength of support is still very tangible today through volunteering fundraising and promotion. It is certainly visible when hospitals are threatened and local people attend public meetings or march through the streets.

Local people clearly have confidence in their local hospital service, and when creating community capacity to enable more people to be treated outside of acute hospitals, this would seem to be a strong basis to build on.  Rather than view cottage/community hospitals as out-dated in this modern high tech world, surely it is better to build on this strong tradition of care and view the trust that the service has earned over generations as a positive factor when designing community-based services.  This is not just about sentimentality and the status of having a local hospital in your community.   Studies have shown the rehabilitation outcomes for older people are positive (3) cost effective (4) appropriate (5) and attract a high level of satisfaction (6). This is a significant service meeting local needs.

And yet their history is one of uncertainty and turbulence, with some hospitals under continual threat of closure or reduced services in the drive for centralisation and specialisation.

For some health economies they are considered to be the answer to managing demand for services such as unscheduled care (minor injuries unit), diagnostic services (X-ray, ultrasound), monitoring and management of long term conditions (clinics and day assessment), as well as rehabilitation and palliative care (inpatient wards). In other areas they are viewed more as a liability than an asset (7).

When assessing community hospitals in the context of national policy, they would appear to fulfil strategic aims: they offer patient choice; they provide intermediate care, they provide a hub for multiple providers to work in an integrated way and they offer care closer to home.   A research programme on community hospitals involving research teams from three universities has just started.  The University of Birmingham study led by Professor Jon Glasby HSMC will focus on building up a database of these hospitals and assessing their contribution to patients and communities.

So although the cottage hospital has evolved over 150 years, its central theme of providing local access, continuity of care through primary health care staff and an opportunity for integrated working would appear to be very current.

Simon Stevens has said that he believes that small hospitals have a big role to play.  Local people have been saying this for many years.



  1. Daily Telegraph, `Simon Stevens: The NHS is at a defining moment’. 29 May 2014.http://www.telegraph.co.uk/health/healthnews/10864008/Simon-Stevens-The-NHS-is-at-a-defining-moment.html 
  1. Tucker, H. (2013) “Discovering Integrated Care in Community Hospitals” Journal of Integrated Care  21:6 pp 336-346
  1. Green et al. (2005)   “Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial.”   Br Med J 331(7512):317-322.
  1. O’Reilly et al (2008)    “Post-acute care for older people in community hospitals–a cost-effectiveness analysis within a multi-centre randomised controlled trial.” Age and Ageing 37(5):513-520.
  1. Garasen et al. (2007)   “Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trial.” BMC Public Health 7:68
  1. Small et al. (2007)  “The patient experience of community hospital – the process of care as a determinant of satisfaction.”   Journal of Evaluation in Clinical Practice: 95-101
  1. Tucker, H (2014)  “We know that community hospitals work. And at last, so does the NHS”    http://www.theguardian.com/commentisfree/2014/may/30/community-hospitals-simon-stevens-nhs

 Any views expressed in this blog are the author’s own and not necessarily those of HSMC or University of Birmingham. © HSMC 2014


The Public Services Social Value Act: the gap between policy and practice


 Viewpoint piece by Dr Jenny Harlock, Research Fellow, HSMC.

In January 2013, assessments of the social value of public services became officially enforced via the Public Services (Social Value) Act (2012). For the first time, public sector commissioners are legally required to consider the wider social, economic and environmental benefits of services in the procurement process. Since then social value has become a key focus for the government’s new Commissioning Academy and a core debate for the cross-government Public Service Transformation Network.

In these tight economic times, the Social Value Act appears to offer an alternative approach to public sector commissioning:in line with the ‘best value’ duty on local authorities, the Act promotes a move away from narrow concerns with cost-efficiency towards achieving maximum value. It is a key dimension to outcomes-based commissioning, as the public sector attempts to commission what is important to service users and communities. It is even an antidote to the fragmenting and divisive effects of austerity politics, signifying what is to be valued collectively in the public realm.

Yet early on concerns have been raised about the potential impact of the legislation due to the limited guidance on how to implement social value in commissioning in practice (Social Enterprise UK, 2012; Cabinet Office, 2012).  Social value is difficult to define, and even harder to measure.

Recent interviews undertaken with adult social care commissioners reveal that commissioners are struggling to find meaningful and user-friendly ways to assess social value. The few established methods that exist such as Social Return on Investment were seen, by some, to be too complex to implement, and not appropriate for either all services or providers. A shared view was that assessing social value requires both different indicators and different skills to analyse and apply it, along with a more flexible procurement process to give providers the freedom to demonstrate the social value of what they do. This is a particular challenge for those working in adult social care: where service users are some of the most vulnerable groups in society, quality and safeguarding responsibilities often take priority in evaluation of services.  At the same time, assessing social value was seen to be instinctive, and the flip-side is that over-analysis could turn it into a “bureaucratic nightmare” (interviewee).

These findings are probably most significant for the third sector – a key driving force behind the legislation (Harlock, 2014). The Social Value Act has been widely heralded as an opportunity to level the playing field for third sector providers vis a vis commercial organisations. For many in the sector, it represents an opportunity to show-case the often praised – but difficult to demonstrate – distinctive ‘added value’ of third sector providers, thereby increasing the sector’s share of public service contracts (Teasdale et al., 2012). But the challenge of measuring social value is also being felt by the sector (Arvidson and Kara, 2013). There are examples of good practice emerging both amongst local authorities and third sector organisations (Hurd, 2014), and the third sector is bringing its expertise to bear on developing methods for demonstrating social impact (see www.inspiringimpact.org). However there is a danger that, faced with increased financial pressures, risk-averse commissioners will stick with what they know.

Implementing the Social Value Act requires significant cultural and behavioural change in the public sector. In the words of one commissioner interviewed:

“we’ve got thirty years of local government culture to unbundle, you’re not going to achieve that in just three or four years”

For the third sector, this means that the challenge of measuring and demonstrating social value is likely – for the time being at least – to remain in its hands.

 You can read the full paper by Jenny Harlock, “From outcomes-based commissioning to social value?” here [http://www.birmingham.ac.uk/generic/tsrc/documents/tsrc/working-papers/working-paper-123.pdf]


Arvidson, M. and Kara, H. 2013 “Putting evaluations to use: From measuring to endorsing social value” Third Sector Research Centre Working Paper 110, University of Birmingham, Birmingham.

Cabinet Office 2012 Procurement policy note – the Public Services (Social Value) Act 2012 – advice for commissioners and procurers. Available at https://www.gov.uk/government/publications/procurement-policy-note-10-12-the-public-services-social-value-act-2012

Harlock, J. 2014 “From outcomes-based commissioning to social value? Implications for performance managing the third sector” Third Sector Research Centre Working Paper 123, University of Birmingham, Birmingham.

Hurd, N. 2014 “One year on: what impact has the Social Value Act had so far?” The Guardian, 4 February 2014. Available at http://www.theguardian.com/social-enterprise-network/2014/feb/04/public-services-social-value-act-nick-hurd.

Social Enterprise UK 2012 The Social Value Guide, Implementing the Public Services (Social Value) Act. Available at http://www.socialenterprise.org.uk/uploads/files/2012/12/social_value_guide.pdf

Teasdale, S., Alcock, P. and Smith, G. 2012 “Legislating for the big society? The case of the Public Services (Social Value) Bill”, Public Money and Management, 32 (3): 201-208.


 Any views expressed in this blog are the author’s own and not necessarily those of HSMC or University of Birmingham. © HSMC 2014



Neena Ramful, Trainee Clinical Psychologist at the University of Birmingham writes our latest Viewpoint Piece 


Today is World Refugee Day, ’’a time to commemorate the strength and resilience of the millions of people around the world who are forced to flee their homes due to war and human rights abuses’’ (unhcr.org; www.stories.unhcr.org/uk).  To date it seems that little is truly understood about the horrific life journeys that refugees encounter before entering a host country.  Not to mention the shock to the adaptation to a new life and culture after suffering many losses (e.g. family, finances, employment, housing) of which may impact on one’s belief about the world being a safe place.  As such refugees may encounter, but not always, psychological distress which may require psychological support.  This is my account of my clinical experience of working with refugees and my interest in researching ways in which, we as professionals can better understand a refugee’s journey in reducing their psychological distress.

Clinical Experience

My experience of working clinically with refugees started within an NHS Primary Care setting where individuals were mainly being referred for psychosomatic complaints (unexplained physical complaints), and more often than not, referrers did not have the time to explore individual’s psychological distress.Before the restrictions of ‘time-limited interventions’ I was able to offer extended psychological assessments to primarily build a positive and safe therapeutic relationship with the individual to explore their reasons for their psychological distress, and refer on to specialist refugee services in the area.

Many refugees would present with severe anxiety, depression but mostly with post-traumatic stress disorder.  Increasing research has been conducted on the prevalence of mental health problems for refugees, which shows that these presentations are not unusual (Bogic et al., 2012; Summerfield, 2001; Fazel, Wheeler & Danesh, 2005).  Sadly research has also shown that many refugees who are experiencing severe mental health problems do not seek support nor are they identified by professionals for many years.  These are due to varying reasons including stigma, lack of access to services and language barriers (Miller, 1999; Plaistow, 2013).  Psychological talking therapy is a westernised approach in exploring and reducing psychological distress.  Therefore refugees from non-western cultures may find the concept of engaging in ‘talking therapies’ to be very different from their own cultural norms; which in turn can further add to the lack of accessing services.

In order to help refugees’ engagement in psychological services, there has been an increased number of policies and research stressing the need for ‘culturally competent’ approaches to health care (Sue, 1996; Eisenbruch et al., 2004).  Cultural competence is met when a clinician is in a position to understand, appreciate and respect the client’s cultural group in order to make adjustments to their clinical practice to suit a client’s needs (Sue, Zane, Hall & Berger, 2008).  These adaptations may include, understanding of the culture and systems, reducing the use of jargon language, understanding the client’s context to their mental health to all help deliver effective interventions.

Further Research

There is little research in understanding how a clinician/professional can offer culturally competent practice. In addition there is also limited information about how and what specific adaptations are made to evidence based therapies and the impacts that these have to the efficacy of the therapy.  What we do know is that it is not necessarily a protocol standard across all cultures but is person centred to the individual’s needs, and cultural background. However, with increasing emphasis on standardisation of therapies, some therapists can lack the confidence or direction in adapting therapies which follow a strict protocol. Existing therapies rarely provide guidance on specific cultural adaptations to therapies that would still maintain their theoretic basis.  There is some emerging research on culturally adapted cognitive behavioural therapy (CA-CBT), which has shown to be effective in reducing the target mental health problem (Hinton et al., 2005; Hinton et al., 2004;  Otto & Hinton, 2006)  However, further research is needed to explore this area in depth with a variety of psychological interventions so that we as professionals can better our clinical practice to become more confident in culturally adapting to an individual’s needs.

As part of my Doctorate in Clinical Psychology I am in the process conducting a qualitative research project with Dr Michael Larkin (Senior Research Tutor, University of Birmingham), Dr Ruth Butterworth (Clinical Psychologist/Academic Tutor, University of Birmingham) and Dr Sobia Khan (Clinical Psychologist from Freedom From Torture*). I am curious to explore how male refugees (who have been subjected to torture) experience psychological therapy. The outcomes from this research may be able to highlight what cultural adaptations were made within therapy (from the perspective of the refugee).  In addition I am interested in understanding whether there are any gender and cultural norms that refugees hold which may be neglected by professionals.  As such it is hoped that the outcomes from this research can both add to the limited literature base, but also to give refugees a voice in aiding clinicians/health professionals in therapeutically engaging in a culturally competent manner.

*Freedom From Torture is a registered charity and Human Rights  organisation which offers a holistic rehabilitation service for individuals who have been subjected to torture. Three key strategic aims of the organisation are rehabilitation, protection and accountability.  For more information  http://www.freedomfromtorture.org/ 

Any views expressed in this blog are the author’s own and not necessarily those of HSMC or University of Birmingham. © HSMC 2014


One million unsung heroes: the secret change leaders of the NHS

mervby Merv Conroy, Senior Fellow at the Health Services Management Centre, University of Birmingham. 

At the NHS Confederation earlier this month, undoubtedly there were some elite speakers: Andy Burnham, Jeremy Hunt, Norman Lamb, Simon Stevens. They had some ‘big ticket’ agendas including co-commissioning, integration, place, patient voice, big data and finance all aimed at doing more for less to a higher standard. They were interesting and in some cases inspiring variations on themes of leadership and change in the search for the answers to how we improve care and secure a sustainable NHS. I can recommend the video summaries at http://conference.nhsconfed.org/watch-again

After I had listened to the last speech I went back to the HSMC stand and found Evelina, Sarah and Tracey (HSMC support staff) all working away.  I started to think about what made the conference tick because it functioned extremely well and I and many people I spoke to had a highly rewarding experience. I concluded it was, for the main part, down to the Evelinas, Sarahs and Traceys of the conference, the unsung heroes, who did so much behind the scenes to keep everything together. I think the NHS is the same. It is the unsung heroes, the frontline and backroom staff, who significantly influence patient experience and will sustain the future of the NHS.  The NHS has given some recognition to its unsung heroes by setting up an award scheme. I tried to access the central website www.nhsheroes.co.uk but it is no longer available. In the ‘defining moment’ era has the NHS left behind its lifeblood?  Not quite- internet traffic indicates that many local trusts are still doing much to support the award.  One of the quotes I found was from the Chair of Frimley Park Hospital NHS Foundation Trust, Sir Mike Aaronson:

‘…those of us who work in the NHS know that it is full of heroes who do a fantastic job, over and above what they are paid for. They do so because they care and have professional pride in what they do’

What have unsung heroes got to do with the theme of change leadership which was so prominent in the elite speeches? According to Buchanan et al (2007) unsung heroes have a lot to do with leadership and change in the NHS. What Buchanan et al say is that organisational changes are often led by the spontaneous concertive action of staff at all levels, not just by senior elite groups. They challenge the notion that leadership transmits downwards from the top and instead argue that inter-organizational, and dispersed transmission processes create conditions supporting the narratives that lead to service improvement.  Developing this theme, Fitzgerald et al (2013) argue that a widely distributed pattern of change leadership is an effective enabler of service improvement, across a range of healthcare contexts and despite adverse conditions. This latter study was based on ten service improvement case studies covering cancer, maternity and diabetes care.  In addition they found that people with both clinical and managerial responsibilities (hybrids in their terminology) perform crucial bridging roles between practices, having the ability to adapt and extend their roles to suit their organizational context. Finally they found that a foundation of good pre-existing relationships underpins the capacity of ‘dispersed leadership’ or the ‘unsung heroes’ to achieve service improvements. Conroy and Kempster (2014) like Fitzgerald et al emphasise the importance of the unsung heroes of middle management who are often caught in ethical conflicts of protecting care practice virtues versus implementing service improvements which pose a threat to those virtues. Conroy and Kempster  argue that the middle management unsung hero group shape the healthcare community through a sense-making role; they are pivotal in the structure of an organisation in terms making sense of the conflicts and finding a way forward that retains both pride and professionalism, just as the quote above also suggests.

What then are the implications of recognising the importance of one million unsung heroes in the NHS to the aspirations of the elite? Fitzgerald et al (2013) question the effectiveness of middle management delayering and individualized, transformational senior leadership development strategies. They suggest that policy makers should recognize the need for strong middle management leadership capacity to realize significant change. Buchanan et al suggests that managing ‘the right conditions’ for the development of dispersed leadership may not be an option, but a requirement. Conroy and Kempster harmonise with Buchanan et al to recognise the importance of leaders listening to the conflicts expressed in the middle-manager narratives of improvement and prioritise supporting them in protecting practice virtues above the external goods of money (e.g. cost cutting), status (e.g. foundation trust status) and power (e.g. taking on more services).  Here I argue that it is not just the middle managers as a group who are important to support but also all the other unsung heroes in the NHS like Evelina, Sarah and Tracey on the HSMC confederation stand who are vital to the standards of care in the NHS and its future sustenance. They need both the ‘right conditions’ and the support to continue going the extra mile.


Buchanan, D.A., Caldwell, R., Meyer, J., Storey, S. and Wainwright, C., (2007)

‘Leadership transmission: a muddled metaphor?’, Journal of Health Organization and Management, vol.21, no.3, pp.246-58.

Conroy, M. and Kempster S. (2014) Protecting organizational virtue: Middle managers and ethical resistance, Journal of Management Enquiry (Forthcoming)

Fitzgerald, L., Ferlie, E., McGivern, G. and Buchanan, D.A., 2013,

‘Distributed leadership patterns and service improvement: evidence and argument from English healthcare’, The Leadership Quarterly, vol.24, no.1, pp.227-239.



Any views expressed in this blog are the author’s own and not necessarily those of HSMC or University of Birmingham. © HSMC 2014


The revolving door turns once more

In our latest Viewpoint Piece HSMC’s Mark Exworthy looks at the debate surrounding national and local approaches to running the English health system

Simon Stevens’ recent pronouncements will revive the long-term debate in the NHS about the balance between national and local approaches to running the English health system. In an interview with the Daily Telegraph, he called for `more local hospitals’1,2. He elaborated this point in his NHS Confederation conference speech when he argued that:

“Just as there’s been a push for centralisation there’s been a pull for more local and community-orientated service”3.

Since its inception, at the heart of the NHS lies a tension between the `national’ and the `local’. The very term `NHS’ seems to infer that it is uniform in scope and delivery. To some extent, this is correct. The NHS remains a single-payer system and funded from central taxation; no (major) political party is willing to rescind this, possibly because its `national’ dimension remains a potent symbol for politicians and the public. For much of the life of the NHS, it has pretended to be centralised in its planning (in terms of, say, staffing or buildings). Many of such vestiges remain. Although reforms by Andrew Lansley have removed some significant powers of the Secretary of State, this doesn’t mean that that ministers (as in previous administrations) have been averse to becoming embroiled in local NHS matters. Indeed, the phone call from the Minister remains a notorious form of direct, local intervention from the centre.

However, the NHS in England has also long been seen as a series of local health services. This is largely due to the local organisation, management and service delivery (from area or district health authorities through to Foundation Trusts and CCGs). Moreover, most people experience their NHS through encounters with local services (as a patient, carer and/or employee) which creates strong ties and loyalty to local health services. This `localism’ is evident in hospitals’ Leagues of Friends, patterns of `patient choice’, and commissioners’ spending decisions (among others). Resistance to `top-down re-organisation’ often ensues.

Throughout its history, the NHS periodically has experienced the swing of the policy pendulum from centralisation to decentralisation – `once more through the revolving door’ as Rudolf Klein once explained4. Of course, the policy imperatives may point to both processes at the same time5! (Note, for example, the tension between national and local HR agreements for different staff groups). It would seem (from Simon Stevens’ comments) that the NHS is on the cusp of one such revolution of the door or swing of the pendulum (at least in terms of the configuration of services).

Policy initiatives such as `Safe and sustainable’ (child cardiac surgery) or cancer networks illustrate the centralisation of services and, no doubt, have some significant (clinical) benefits. Yet, some see such concentration as inimical to better access or question the claims of enhanced effectiveness or financial calculations6; as a result, campaigns (resisting centralisation) have been prominent.

Although the centralisation of acute services (with some political and clinical support) appears unstoppable, the apparently immovable object of localism stands in its way. Concerns about clinical effectiveness and economies of scale thus need to be weighed against the `postcode lottery’, local responsiveness and barriers to innovation. Greater responsiveness to local (clinical and organisational) needs is to be welcomed if it can also be accompanied by greater local democratic legitimacy and foster locally-owned innovation. However, equally, a robust framework is required to moderate the excesses of such as system. For example, redistributive funding appears effective in redressing some health inequalities7.

As recent events have shown, the revolving door continues to function. The consequences, however, have yet to be revealed.



1.      Daily Telegraph, `Simon Stevens: The NHS is at a defining moment’. 29 May 2014. http://www.telegraph.co.uk/health/healthnews/10864008/Simon-Stevens-The-NHS-is-at-a-defining-moment.html

2.      BBC, `New NHS chief Simon Stevens backs more local hospitals.’ 30 May 2014 http://www.bbc.co.uk/news/health-27631081

NHS England, Speech by Simon Stevens, CEO NHS England, to the NHS Confederation Annual Conference 2014.4 June 2014 http://www.england.nhs.uk/2014/06/04/simon-stevens-speech-confed/

Klein, R. `The new localism: once more through the revolving door?’ J Health Serv Res Policy 2003, 8: 195.

5.      Exworthy, M. et al, Decentralization and performance: autonomy and incentives in local health economies. 2009. HSDR research report http://www.nets.nihr.ac.uk/projects/hsdr/081618125

6.      Jones, L., Exworthy, M and Frosini, F. (2013) `Implementing market-based reforms in the English NHS: bureaucratic coping strategies and social embeddedness.’ Health Policy, 111, 1, pp.52-59

7.      Barr, B. et al, `The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study.’ BMJ, 2014; 348 (27 May 2014) http://www.bmj.com/content/348/bmj.g3231

Any views expressed in this blog are the author’s own and not necessarily those of HSMC or University of Birmingham. © HSMC 2014


Privatisation: what’s in a word?

miller-robin2powell-martinIn our latest Viewpoint Piece Robin Miller, Senior Fellow and Martin Powell, Professor of Health and Social Policy at HSMC discuss Privatisation and ask what’s in a word?

Of all the debates regarding the future of the NHS, the one surrounding the term ‘privatisation’  is likely to generate the most passion, argument and (at times) animosity.  For some, any increase contributes to the destruction of a much loved and needed public institution either by intent or default, with concerns (particularly in the early days of the coalition) that we will soon reach a tipping point beyond which the NHS will never recover. Others see the private sector as bringing much needed innovation, investment and efficiency to a bureaucratic and bloated set of organisations, either through replacing what is currently delivered or ensuring that they have to compete to survive. For others again, the whole issue has been blown out of proportion as the push for diversification under New Labour and now the Coalition has not resulted in the majority of the NHS being transferred out of public sector control. Privatisation has led to the launch of campaigning groups and indeed political parties, mud-slinging in parliament as the opposing benches attempt to make or defend accusations of being the ones to sell off the NHS, and heated arguments between respected academics.

Never has the lens through which we choose to interpret policy seemed so influential in shaping our judgement. For example, personal health budgets – an exciting opportunity to address professional domination, or a dangerous incursion into consumer based market pressures? Social enterprises – community orientated mutuals, or trojan horses for the private sector? In this debate seemingly arbitrary lines have been drawn  – for example is a NHS Foundation Trust whose income is 30% derived from private sources more acceptable than one with 40% of private income? Furthermore at times there can appear to be amnesia regarding what the original NHS looked like – the right to private practice for consultants was embedded from the start, general practitioners have always been self-employed independent contrractors, and the NHS has relied on private companies to supply goods and services from the outset.

Just because a discussion is tricky does not mean it is not important though, and whatever one’s perspective it would be naïve not to recognise that this is an issue of great importance and therefore worthy of reasoned and objective analysis. However doing so will require us to be clearer about what we mean by privatisation. Is it a decrease in the role of public sector or an increase in the role of the private? Do charities, social enterprise or voluntary groups count as public, private or neither? Is it more important who funds or provides a health service? Can strong regulation diminish (for better or worse) a change of provider?

Only once we are clearer about what mean can we begin to meaningfully explore the many and complex impacts of increasing the role of the private sector. Otherwise, to paraphrase Louis Armstrong, we will be stuck at ‘you say privatisation…I say marketisation’ for a long time to come.

Two recent articles by Professor Martin Powell and Robin Miller explore these issues in more depth

In Journal of Health Politics, Policy & Law they explore the use of the ‘p word’ by different groups such as politicians, clinicians, the public and campaigning groups. http://jhppl.dukejournals.org/content/38/5/1051.full

In Journal of Social Policy they compare privatisation through three different lenses: the approaches of the Mixed Economy of Welfare, Wheels of Welfare and Publicness.

Robin Miller is a Senior Fellow at HSMC and from August 2014 will be the director of consultancy.

Martin Powell is Professor of Health and Social Policy at HSMC and is the current director of research.

Any views expressed in this blog are the author’s own and not necessarily those of HSMC or University of Birmingham.

© HSMC 2014