Financial and clinical risk in health care reform: a view from below

Objectives This paper examines how the interaction between financial and clinical risk at two critical phases of health care reform in England has been experienced by frontline staff caring for vulnerable patients with long term conditions. Methods The paper draws on contracting theory and two interdisciplinary and in-depth qualitative research studies undertaken in 1995 and 2007. Methods common to both studies included documentary analysis and interviews with managers and front line professionals. The 1995 study employed action-based research and included observation of community care; the 2007 study used realistic evaluation and included engagement with service user groups. Results In both reform processes, financial risk was increasingly devolved to frontline practitioners and smaller organisational units such as GP commissioning groups, with payment by unit of activity, aimed at changing professionals’ behaviour. This financing increased perceived clinical risk and fragmented the delivery of health and social care services requiring staff efforts to improve collaboration and integration, and created some perverse incentives and staff demoralisation. Conclusions Health services reform should only shift financial risk to frontline professionals to the extent that it can be efficiently borne. Where team work is required, contracts should reward collaborative multi-professional activity

Scheduling operating rooms: achievements, challenges and pitfalls

In hospitals, the operating room (OR) is a particularly expensive facility and thus efficient scheduling is imperative. This can be greatly supported by using advanced methods that are discussed in the academic literature. In order to help researchers and practitioners to select new relevant articles, we classify the recent OR planning and scheduling literature into tables regarding patient type, used performance measures, decisions made, OR up- and downstream facilities, uncertainty, research methodology and testing phase. Based on these classifications, we identify trends and promising topics. Additionally, we recognize three common pitfalls that hamper the adoption of research results by stakeholders: the lack of a clear choice of authors on whether to target researchers (contributing advanced methods) or practitioners (providing managerial insights), the use of ill-fitted performance measures in models and the failure to understandably report on the hospital setting and method-related assumptions. We provide specific guidelines that help to avoid these pitfalls. First, we show how to build up an article based on the choice of the target group (i.e., researchers or practitioners). Making a clear distinction between target groups impacts the problem setting, the research task, the reported findings, and the conclusions. Second, we discuss points that need to be considered by researchers when deciding on the used performance measures. Third, we list the assumptions that need to be included in articles in order to enable readers to decide whether the presented research is relevant to them