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Reports a postal survey of 175 senior district health authority managers to determine the extent to which the Effective Health Care (EHC) bulletin No. 1 has effectively disseminated the results of a systematic review of the effectiveness of population‐based bone density screening for osteoporosis to health care commissioners in district health authorities; and a supplement outlining the process of critical appraisal. The information in the bulletin was perceived by a large majority as “correct”. A positive correlation was found between confidence to act and having read about the process of critical appraisal. Confidence to act was strongly correlated with a stated intention to use the bulletin in situations relating to the purchase of bone density screening for osteoporosis and also with the view that the bulletin would be influential in local discussions. Further research is needed to assess the impact on decision making.

The NHS review has implications for the funding of teaching hospitals and the relationship between them and the medical schools. The ring‐fencing of the Service Increment for Teaching and Research (SIFTR) and the need to develop contractual relationships for the provision of service facilities for teaching and research means that more information is needed on the nature and distribution of the service costs of these activities. The article describes research which informed the process of allocating SIFTR in a large teaching district. A methodology for developing rational SIFTR contracts is described and the implications for the future of medical education and research discussed. The local distribution of SIFTR must be well managed if teaching and research are not to suffer as a result of the financial pressures generated by the NHS review.

The purpose of this paper is to explore the dilemma facing the health staff regarding the achievement of targets (waiting list reduction, etc.), on the one hand, and, on the other hand, the responsibility of continuously improving the healthcare quality in NHS organisations.

In‐depth interviews were conducted using a semi‐structured interview method with a heterogeneous group of 33 key persons who have important responsibilities in an NHS Hospital Trust. The case study method was adopted to understand how the health staff are coping with the dilemma of meeting targets, on the one hand, and, on the other hand, continuously improving the quality of care (a statutory duty imposed on every member of health staff under clinical governance framework).

The findings of the research suggest that clinical governance has increased the dilemma of health staff on how to meet targets while continuously improving the quality of clinical care. The departments get additional funds only when it is clearly demonstrated that funds will be used to meet targets, whereas such additional funding is not available for quality improvement activities. Consequently, meeting targets becomes a priority, while achieving continuous quality improvement takes a backseat.

In view of the mounting pressure on health staff to deliver the highest quality of clinical care more speedily, more research on a wider scale is necessary to understand what could be a practical solution for reducing the tensions of health staff and delivering the highest quality of care.

The research points out that it is almost impossible to continuously improve service quality to higher standards while meeting quantitative targets, because improving quality of healthcare would require allocation of more time to each patient and subsequent quality improvement activities. Putting too many patients through the system may reduce waiting lists but it may increase the risk of clinical errors because less time is available for individual patients.

The current literature provides little information on the above issue. The paper makes a valuable contribution by highlighting the failure of clinical governance to address some of the fundamental issues facing the NHS organisations. The managerial concepts of improving both quality and quantity at the same time may not be workable in healthcare organisations, because of the unique characteristics (i.e. the human dimension of clinical decision making) of healthcare management.

The idea that patients should be informed about the benefits and risks of treatment options and involved in decisions about their care is, to many people, appealing and sensible. However, it has important implications. This paper briefly considers two motivations for involving patients in clinical decisions and explores some of the issues raised by these. It then makes some practical suggestions for those wanting to provide information to support patient involvement. The paper emphasizes that although the provision of more good‐quality information to patients is widely accepted to be a priority, it is not always a straightforward matter and warrants critical consideration. Substantial resources may be needed if it is to be done well.

Purpose – This chapter gives an overview of meta-analytic methods and illustrates the use of these methods for synthesising research findings. The advantages of performing a meta-analysis are described. Pitfalls in meta-analyses are also discussed. The chapter is intended to present the main elements of a meta-analysis and guide readers to literature presenting meta-analytic methods in greater detail.

Methodology – Key references in the meta-analysis literature are quoted and examples of meta-analyses are presented.

Findings – A meta-analysis is a useful tool for summarising knowledge in fields where a large number of studies have been reported. In addition to providing summary estimates of results, a meta-analysis can be applied to identify factors that produce systematic variation in study findings.

Research implications – Methods of meta-analyses keep developing to deal with complex data structures, thus extending the type of research findings that are amenable to meta-analyses.

Practical implications – Performing a meta-analysis saves labour by eliminating the need to read and digest a large number of studies in order to get an overview of the current state-of-knowledge in a field. Moreover, a meta-analysis establishes a system for easily and quickly updating knowledge as new studies become available.

In this chapter, we address the question of what health economic models represent. Are they realistic? And, does model realism matter? Or, is model usefulness in terms of informing pricing, reimbursement, and prescribing decisions all policymakers care about? The usefulness of models is circumscribed given that: (1) market failure is inherent in healthcare and (2) models oversimplify the preference structure underlying choices. We suggest, however, that models which employ the ceteris paribus clause can be useful in order to isolate factors that play a role in healthcare decision-making and ultimately characterize agents’ multiattribute utility functions through discrete choice experiments. As a result, policymakers gain important knowledge about decision criteria in the healthcare system.

Aim: To assess the potential for improved clinical effectiveness through the use of research‐based evidence in obstetric care. Design: A questionnaire survey to obtain evidence about (i) the usage of reviews of controlled perinatal trials, and (ii) the attitudes of professionals towards the reviews and their practice, relating to 27 areas of clinical care addressed by the reviews. Subjects and setting: All doctors and midwives working in two teaching hospital maternity units (Units X and Y). Main outcome measures: The use of the reviews. For each of the 27 areas of clinical care, (i) whether a majority of professionals were in agreement with research‐based evidence, and (ii) how perceived current practice compared with research‐based evidence. Results: For most areas of clinical care (21/27 in unit X, 20/27 in unit Y) a majority of professionals agreed with the research‐based evidence. However, for a large proportion of these areas (16/21 in unit X, 12/20 in unit Y), practice appeared to be inconsistent with research‐based evidence. Conclusion: There is a considerable opportunity to improve clinical effectiveness, as in many of the areas of care examined professionals agree with research‐based evidence, but clinical practice appears to be inconsistent. The approach used in this study could be used to help develop practices for promoting clinical effectiveness.

Principal-agent theory (PAT) has been used to understand relationships among different professional groups and explain performance management between organisations, but is rarely used for research within primary care. The purpose of this paper is to explore whether PAT can be used to attain a better understanding of performance management in primary care.

Purposive sampling was used to identify a range of general practices in the North-west of England. Interviews were carried out with directors, managers and clinicians in commissioning and regional performance management organisations and within general practices, and the data analysed using matrix analysis techniques to produce a case study of performance management.

There are various elements of the principal-agent framework that can be applied in primary care. Goal alignment is relevant, but can only be achieved through clear, strategic direction and consistent interpretation of objectives at all levels. There is confusion between performance measurement and performance management and a tendency to focus on things that are easy to measure whilst omitting aspects of care that are more difficult to capture. Appropriate use of incentives, good communication, clinical engagement, ownership and trust affect the degree to which information asymmetry is overcome and goal alignment achieved. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation.

The principal-agent theoretical framework can be used to attain a better understanding of performance management in primary care; although it is likely that only partial goal alignment will be achieved, dependent on the extent and level of alignment of a range of factors.

Elderly population We all have a vested interest in the care of our elderly, whose needs and expectations are as important as those of younger people.

Fundholding (the opportunity to hold a budget at practice level) has given general practitioners (GPs) purchasing power for medical services within the reformed UK National Health Service (NHS). This new purchasing power equates to financial leverage with the NHS consultants in hospitals. Argues that fundholding is presented as an opportunity for GPs to engage in a “turf battle” with the hospital consultants without this battle becoming publicly visible. Fundholding as an accounting‐based intervention masked the nature of the professional challenge which GPs launched against the consultants and, hence, allowed territorial claims to be renegotiated through the medium of contracting. This circumvented the damage to medical professional ideologies which would have ensued if intra‐professional conflicts had become overt. The empirical study which is referred to indicates that GPs are using contracts to improve processes of case management at the hospital interface (an area where consultants have failed to communicate with GPs) and to have an input into the setting of quality standards within the hospitals. The increased financial flexibility conferred through holding budgets is also enabling GPs to expand in‐house services for primary care. Theorizes the changing power relations between GPs and consultants through exploring four dimensions of intra‐professional differentiation: task specialization; client differentiation; organization of work; and career pattern. Concludes that budgets have constituted a catalyst for professional development through reconnecting the monetary bonds between the polarized professionals in British medicine. This study indicates that, as fundholding progresses, the boundary between primary and secondary care is becoming blurred; that lead fundholding GPs are being managerialized; and that the purchasing dialogue between the GPs and the Trusts is marginalizing the role of the Health Boards (bodies which had previously held sole responsibility for the co‐ordination and delivery of health care but which now have a more limited purchasing/commissioning role).