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Article
Publication date: 30 January 2020

Iain Snelling, Mark Exworthy and Shahin Ghezelayagh

The purpose of the study is to evaluate the first cohort of the Royal College of Physicians' (RCP) Chief Registrar programme in 2016/7. Chief Registrars provide medical…

Abstract

Purpose

The purpose of the study is to evaluate the first cohort of the Royal College of Physicians' (RCP) Chief Registrar programme in 2016/7. Chief Registrars provide medical leadership capacity through leadership development posts.

Design/methodology/approach

The study adopted a mixed methods design, comprising a monthly survey of the 21 Chief Registrars in the first cohort, interviews with Chief Registrars, and six cases studies where Chief Registrars and colleagues were interviewed.

Findings

Chief Registrars enjoyed high levels of practical, professional, and leadership support from their employing organisations, the RCP, and the Faculty of Medical Leadership and Management. They had high degrees of autonomy in their roles. As a result, roles were enacted in different ways, making direct comparative evaluation problematic. In particular, we identified variation on two dimensions: first, the focus on medical leadership generally, or quality improvement more specifically, and second, the focus on personal development or organisational leadership capacity.

Research limitations/implications

The data are limited and drawn from the first cohort's experience. The Chief Registrar scheme, unlike many other leadership fellowships, maintains a high level of clinical practice (with a minimum 40 per cent leadership work). This suggests a clearer preparation for future hybrid leadership roles.

Practical implications

This paper may offer some support and guidance for Chief Registrars and those who work with and support them.

Originality/value

This study adds to the literature on leadership development for doctors in hybrid roles, and highlights the distinctiveness of the scheme compared with other schemes.

Details

Journal of Health Organization and Management, vol. 34 no. 1
Type: Research Article
ISSN: 1477-7266

Keywords

Content available
Article
Publication date: 5 July 2019

Rod Sheaff, Joyce Halliday, Mark Exworthy, Alex Gibson, Pauline W. Allen, Jonathan Clark, Sheena Asthana and Russell Mannion

Neo-liberal “reform” has in many countries shifted services across the boundary between the public and private sector. This policy re-opens the question of what structural…

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Abstract

Purpose

Neo-liberal “reform” has in many countries shifted services across the boundary between the public and private sector. This policy re-opens the question of what structural and managerial differences, if any, differences of ownership make to healthcare providers. The purpose of this paper is to examine the connections between ownership, organisational structure and managerial regime within an elaboration of Donabedian’s reasoning about organisational structures. Using new data from England, it considers: how do the internal managerial regimes of differently owned healthcare providers differ, or not? In what respects did any such differences arise from differences in ownership or for other reasons?

Design/methodology/approach

An observational systematic qualitative comparison of differently owned providers was the strongest feasible research design. The authors systematically compared a maximum variety (by ownership) sample of community health services; out-of-hours primary care; and hospital planned orthopaedics and ophthalmology providers (n=12 cases). The framework of comparison was the ownership theory mentioned above.

Findings

The connection between ownership (on the one hand) and organisation structures and managerial regimes (on the other) differed at different organisational levels. Top-level governance structures diverged by organisational ownership and objectives among the case-study organisations. All the case-study organisations irrespective of ownership had hierarchical, bureaucratic structures and managerial regimes for coordinating everyday service production, but to differing extents. In doctor-owned organisations, the doctors’, but not other occupations’, work was controlled and coordinated in a more-or-less democratic, self-governing ways.

Research limitations/implications

This study was empirically limited to just one sector in one country, although within that sector the case-study organisations were typical of their kinds. It focussed on formal structures, omitting to varying extents other technologies of power and the differences in care processes and patient experiences within differently owned organisations.

Practical implications

Type of ownership does appear, overall, to make a difference to at least some important aspects of an organisation’s governance structures and managerial regime. For the broader field of health organisational research, these findings highlight the importance of the owners’ agency in explaining organisational change. The findings also call into question the practice of copying managerial techniques (and “fads”) across the public–private boundary.

Originality/value

Ownership does make important differences to healthcare providers’ top-level governance structures and accountabilities and to work coordination activity, but with different patterns at different organisational levels. These findings have implications for understanding the legitimacy, governance and accountability of healthcare organisations, the distribution and use power within them, and system-wide policy interventions, for instance to improve care coordination and for the correspondingly required foci of healthcare organisational research.

Details

Journal of Health Organization and Management, vol. 33 no. 7/8
Type: Research Article
ISSN: 1477-7266

Keywords

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Article
Publication date: 26 July 2021

James Brackley, Penelope Tuck and Mark Exworthy

This paper examines the contested value of healthy life and wellbeing in a context of severe austerity, exploring how the value of “Public Health” is constructed through…

Abstract

Purpose

This paper examines the contested value of healthy life and wellbeing in a context of severe austerity, exploring how the value of “Public Health” is constructed through and with material-discursive practices and accounting representations. It seeks to explore the political and ethical implications of constructing the valuable through a shared consensus over the “facts” when addressing complex, multi-agency problems with long time horizons and outcomes that are not always easily quantifiable.

Design/methodology/approach

The theorisation, drawing on science and technology studies (STS) scholars and Karen Barad's (2007) agential realism, opens up the analysis to the performativity of both material and discursive practices in the period following a major re-organisation of activity. The study investigates two case authorities in England and the national regulator through interviews, observations and documentary analysis.

Findings

The paper demonstrates the deeply ethical and political entanglements of accounting representations as objectivity, consensus and collective action are constructed and resisted in practice. It goes on to demonstrate the practical challenges of constructing “alternative accounts” and “intelligent accountabilities” through times of austerity towards a shared sense of public value and suggests austerity measures make such aims both more challenging and all the more essential.

Originality/value

Few studies in the accounting literature have explored the full complexity of valuation practices in non-market settings, particularly in a public sector context; this paper, therefore, extends familiar conceptual vocabulary of STS inspired research to further explore how value(s), ethics and identity all play a crucial role in making things valuable.

Details

Accounting, Auditing & Accountability Journal, vol. 34 no. 7
Type: Research Article
ISSN: 0951-3574

Keywords

Content available
Article
Publication date: 14 February 2020

Rod Sheaff, Verdiana Morando, Naomi Chambers, Mark Exworthy, Ann Mahon, Richard Byng and Russell Mannion

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial…

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Abstract

Purpose

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.

Design/methodology/approach

We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N = 154), analysis of policy documents (N = 111) and an action learning set, began in 2010–12, with additional data collection from key informants and administrative documents continuing in 2018–19 to supplement and update our findings.

Findings

Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load ‘ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed ‘floor' volume.

Research limitations/implications

Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the ‘managerial workaround’ still further.

Practical implications

In the case of DRGs, the managerial workarounds were instances of ‘constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the ‘managerial workaround'.

Social implications

Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.

Originality/value

So far as we are aware, no other study presents and tests the concept of a ‘managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

Details

Journal of Health Organization and Management, vol. 34 no. 3
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 1 April 1996

Mark Exworthy, Andrea Steiner and Sue Barnard

Clinical Audit has reached a crucial point in its development. In this article, we report the results of a multi‐professional consensus conference held to consider the…

Abstract

Clinical Audit has reached a crucial point in its development. In this article, we report the results of a multi‐professional consensus conference held to consider the likely direction of Clinical Audit in the future. In a structured exercise, small groups identified four priority areas: integration of Clinical Audit with research and development, clinical effectiveness and evidence‐based medicine; development of audit methodologies; emphasis on multi‐professional approaches; and incorporation of Clinical Audit into purhasers' and providers' business planning cycles. Reconfigured groups then formulated specific recommendations in each priority area, to be addressed to clinicians, provider managers, purchasers, and the DoH/NHS Executive. Recommendations were validated by all conference practicipants post‐hoc.

Details

Journal of Clinical Effectiveness, vol. 1 no. 4
Type: Research Article
ISSN: 1361-5874

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Article
Publication date: 2 November 2010

Mark Exworthy, Glenn Smith, Jonathan Gabe and Ian Rees Jones

In recent years, the clinical performance of named cardiac surgeons in England has been disclosed. This paper aims to explore the nature and impact of disclosure of…

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408

Abstract

Purpose

In recent years, the clinical performance of named cardiac surgeons in England has been disclosed. This paper aims to explore the nature and impact of disclosure of clinical performance.

Design/methodology/approach

The paper draws on literature from across the social sciences to assess the impact of disclosure, as a form of transparency, in improving clinical performance. Specifically, it employs the “programme theory” of disclosure.

Findings

The “programme theory” of disclosure involves identification, naming, public sanction and recipient response. Named individual (consultant) surgeons have been identified through disclosure but this masks the contribution of the clinical team, including junior surgeons. Mortality is the prime performance measure but given low mortality rates, there are problems interpreting this measure. The naming of surgeons has been achieved through disclosure on web sites, developed between the health‐care regulator and the surgical profession itself. However, participation remains voluntary. The intention of disclosure is that interested parties (especially patients) will shun poorly performing surgeons. However, these parties' willingness and ability to exercise this sanction appears limited. Surgeons' responses are emergent but about a quarter of surgeons are not participating currently. Fears that surgeons would avoid high‐risk patients seem to have been unrealised. While disclosure may have a small effect on individual reputations, the surgical profession as a whole has embraced disclosure.

Originality/value

While the aim of disclosure has been to create a transparent medical system and to improve clinical performance, disclosure may have the opposite effect, concealing some performance issues and possibly strengthening professional autonomy. Disclosure therefore represents greater transparency in health‐care but it is uncertain whether it will improve performance in the ways that the policy intends.

Details

Journal of Health Organization and Management, vol. 24 no. 6
Type: Research Article
ISSN: 1477-7266

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Article
Publication date: 2 November 2010

Justin Waring, Mary Dixon‐Woods and Karen Yeung

This paper aims to outline and comment on the changes to medical regulation in the UK that provide the background to a special issue of the Journal of Health Organization

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1673

Abstract

Purpose

This paper aims to outline and comment on the changes to medical regulation in the UK that provide the background to a special issue of the Journal of Health Organization and Management on regulating doctors.

Design/methodology/approach

This paper takes the form of a review.

Findings

Although the UK medical profession enjoyed a remarkably stable regulatory structure for most of the first 150 years of its existence, it has undergone a striking transformation in the last decade. Its regulatory form has mutated from one of state‐sanctioned collegial self‐regulation to one of state‐directed bureaucratic regulation. The erosion of medical self‐regulation can be attributed to: the pressures of market liberalisation and new public management reforms; changing ideologies and public attitudes towards expertise and risk; and high profile public failures involving doctors. The “new” UK medical regulation converts the General Medical Council into a modern regulator charged with implementing policy, and alters the mechanisms for controlling and directing the conduct and performance of doctors. It establishes a new set of relationships between the medical profession and the state (including its agencies), the public, and patients.

Originality/value

This paper adds to the literature by identifying the main features of the reforms affecting the medical profession and offering an analysis of why they have taken place.

Details

Journal of Health Organization and Management, vol. 24 no. 6
Type: Research Article
ISSN: 1477-7266

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Book part
Publication date: 28 June 2021

Usman Khan and Federico Lega

Abstract

Details

Health Management 2.0
Type: Book
ISBN: 978-1-80043-345-8

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Article
Publication date: 25 September 2009

Teresa Carvalho and Rui Santiago

The purpose of this paper is to explore the way gender may be used as an instrument to avoid New Public Management (NPM) potential processes of deprofessionalisation in nursing.

Abstract

Purpose

The purpose of this paper is to explore the way gender may be used as an instrument to avoid New Public Management (NPM) potential processes of deprofessionalisation in nursing.

Design/methodology/approach

In total, 83 nurses with managerial duties were interviewed in autonomous and corporate public hospitals in Portugal.

Findings

Nurses used gender as an argument to legitimate their presence in management, and in this way, to keep their control over the profession. Gender stereotypes were used to legitimate their position in two different ways. Firstly, nurses reproduced and reinforced gendered inequality by supporting their male colleagues careers. Secondly, they valorised their feminine skills sustaining that women were in better position to manage hospitals as an extended role from the private domain.

Research limitations/implications

The paper uses a sample from only one country and care must be taken when extrapolating conclusions to the wider population.

Practical implications

Acknowledges the way NPM reinforces gender stereotypes and contributes to redefine professionalism.

Originality/value

Recognition of the complexity and diversity of gender issues in the organisational context and in the structuration of professional legitimacy.

Details

Equal Opportunities International, vol. 28 no. 7
Type: Research Article
ISSN: 0261-0159

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Article
Publication date: 25 May 2012

Gianluca Veronesi and Kevin Keasey

The paper aims to investigate the collective behaviour of boards of directors in 22 English National Health Service trusts and how this impacts on the exercise of their…

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1208

Abstract

Purpose

The paper aims to investigate the collective behaviour of boards of directors in 22 English National Health Service trusts and how this impacts on the exercise of their role and functions. Furthermore, it aims to shed light on the governance model characterising boards of health sector organisations.

Design/methodology/approach

The data were gathered using a range of qualitative techniques (96 semi‐structured interviews, focus groups, workshops and document analysis) with a multiple case study approach.

Findings

Owing to the existence of overlapping governance ideologies, health care boards are characterised by different internal dynamics, processes and levels of engagement in the exercise of their tasks. Post‐new public managment driven boards emphasise a pronounced collective approach in their internal proceedings, a wider perspective in strategising and a greater stakeholder involvement in decision‐making processes. These characteristics are particularly evident in boards of foundation trusts, in which network driven governance principles and mechanisms receive a more comprehensive implementation through a collective leadership approach.

Practical implications

The model of the board shared by foundation trusts moves these health care organisations closer to the idea of social enterprises. Additionally, the evidence shows similar behavioural characteristics between these boards and the best practice examples of private sector boards.

Originality/value

The foundation trust model of the board provides new meaningful connotations and significance to the traditional understanding of health care boards, offering a more comprehensive notion of their role and functions in terms of leadership provision, strategy formulation, monitoring and reporting.

Details

International Journal of Public Sector Management, vol. 25 no. 4
Type: Research Article
ISSN: 0951-3558

Keywords

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