How has New Public Management and Public Value Management been applied to the British National Health Service?
In this essay, I will be discussing key concepts of New Public Management (NPM) before briefly examining its influence upon the British National Health Service (NHS). Following this, I will discuss ideas surrounding Public Value Management (PVM) and examine how they have been applied towards the NHS.
To begin, I will first discuss the theoretical groundings of NPM, before examining the particular case of the NHS. Following this, notions of PVM will be discussed, before examining how it has been applied. Concerning the NHS, the long-standing health institution was on the receiving end of wide, growing dissatisfaction from the British public. Due to this, the British government introduced practises of NPM and PVM in order to respond to changing demographics and beliefs in relation to citizenship and consumerism, along with the “transformations of welfare states operating within a framework of neoliberal policies” .
As cited by many authors , NPM is often widely debated, leading to the articulation of various definitions, yet, many of which overlap with one another . Within such deliberations, Research Professor of Public Management, Christopher Pollitt, draws together varying themes of which summarize NPM. Before outlining particular characteristics, Pollitt broadly suggests that NPM leads from an adaption of private sector ideals that are placed into the public sector.
Drawing from Pollitt’s proposals, he further suggests that NPM includes numerous features that are applicable to differing public sectors. Here, as I am focusing upon a British health institution, I have isolated two areas that I feel are particularly relevant. Firstly, Pollitt suggests NPM has an explicit focus upon ‘management systems and efforts from inputs (for example staff, buildings) and processes (for example teaching, inspecting) towards outputs (test results, inspection reports)’ . Moreover, another key concept of NPM outlined by Christopher Pollitt, includes a ‘shift towards more measurement and quantification, especially in the form of systems of ‘performance indicators’ and/or explicit ‘standards” . Upon such deliberations, Pollitt applies health care examples, stating that ‘instead of just ‘trusting the doctor’, one develops measures which show how often the doctor prescribes certain drugs compared with her peers, how often her patients develop post-operative complications, how long are her waiting lists, how far she complies with the best practice protocols established by the royal colleges of medicine, and so on’ .
In relation to the NHS, these features of NPM have been applied, initially through focusing upon outputs over inputs, where outputs are now managed to ensure improved efficiency and quality. Here, the British government can be seen to introduce performance management ideals, which have included the setting of targets and monitoring via audits . Further examples of such practises, can be seen through the NHS Performance Framework, which provides a thorough assessment of the performance of NHS providers (that are not yet NHS Foundation Trusts) against minimum standards . In practise, this has included the introduction of Strategic Health Authorities (SHAs) and Primary Care Trust (PCT) commissioners who are obligated to take swift and decisive action if organisations do not meet these minimum standards. This in turn leads to providing higher quality services for local communities as they are put under much more routine observation and evaluation. Additionally, Clinical quality indicators (CQI’s) have been introduced in surgical audits. Here, audit process indicators determine whether a patient is getting sicker or better under NHS care. This has led to the development of measurements, or metrics, which assess clinical performance.
Upon such ideals and practises, the NHS also now provides more information to the public, discussing at length, how professionals are performing. This can be seen with the introduction of the GP patient survey, which assesses patients’ experience of healthcare services provided by GP surgeries, including experience of access to GP surgeries, making appointments, the quality of care received from GPs and practice nurses . Upon introducing such measures, Professor Sir Bruce Keogh, the medical director of NHS England, suggested: “This is a major breakthrough in NHS transparency. We know from our experience with heart surgery that putting this information into the public domain can help drive up standards. That means more patients surviving operations and there is no greater prize than that” .
According to the Professor of Public Administration Erasmus University Rotterdam, Erik-Hans Klijn, such performance management methods allow governments to ‘guide at a distance, using performance indicators and market mechanisms to arrange services and secure policy outputs’ . Such methods can be seen to have had a de-centralizing effect upon governance as a whole. This can be argued as through outlining clear goals, steering with clear and cleverly designed incentives, implementation is then left to other organizations . Klijn suggest that this opposes centralized governance in theory, as governance tends to emphasize the horizontal relationships between governmental organizations and other organizations .
Moreover, away from these concepts of NPM, another area that is worth discussing includes the incorporation of Public Value Management (PVM) in the Study of Policy and Management. Within scholarly discussions on this area, Mark Rutgers, Professor of Philosophy of Public Administration in the Faculty of Social and Behavioral Sciences at the University of Amsterdam (UvA) offers various insights. Rutgers suggest that ‘public values are being promoted as a core concept in the study of public administration’ . Within his studies, Rutgers offers varying and often at length definitions of public values, ranging from defining them as enduring beliefs in the organization of and activities in a society that are regarded as crucial or desirable and on the other hand, suggesting public values encompass normative ideals of human society—the Good Society, the Common Wealth, the General Interest.
In this case, I will be drawing the overlap between Public Value Management and New Public Management. In doing so, using my case of the NHS, it can be seen that to improve the overall standards of the institution, the NHS has incorporated public value at it core. Here, it has been said that traditional public values such as citizenship, representation, impartiality, equality and justice, are now being replaced with market values such as consumerism, competition, productivity and profitability . In response to such value changes, the NHS is faced with numerous public value challenges, including providing consistency, resources, a high level of care regardless of internal and external financial changes and overall maintenance of public health.
In response to such problems, the NHS has subcontracted many previously publicly outsourced tasks towards private sector management. Examples of these include catering, cleaning and laundry services, which are now run by the private sector. In doing so, it has been said that previously it was seen that ‘in house’ provision was inefficient because it did not have to be competitive .
Rutgers also often articulates the difficulty in measuring public value, where he concludes that the concept of public value is a fuzzy concept . In relation to this, the NHS has adopted a ‘strategic triangle’, which enables public managers to make sense of their complex environments . The NHS public value strategic triangle featured below introduces the role of a public value manager, who is able to asses and measure public value.
Fig. 1. “The Strategic Triangle”
In practise, the NHS has applied the strategic triangle to “Interpreting the 2020 vision” . Here, the public value proposition in the 2020 Vision is that “by 2020 everyone is able to live longer healthier lives at home, or in a homely setting” . Such propositions have been based upon public value, through identifying public value outcomes, such as acute to community based care, authorizing environment through prioritizing community care at a local level rather than a whole nation vision. Additionally, public value has been measured through the triangle in operational capability, including notions as how to operate with limited resource capability through an “assets-based approach” in co-producing public value. Here, it has been suggested that a partnership will be built between public bodies, local communities and individuals who are responsible for ensuring health outcomes for not just them, but others.
In conclusion, the NHS has certainly responded to increased external and internal pressure through adopting modes of new governance. Although, in this essay I cannot evaluate the efficiency and weigh the benefits and limitations of each practice, the NHS has adapted to a series of policy reforms and reorganizations. However, through a new impetus that is focused upon the setting of targets, goals, outcomes and budgets, it will be interesting to asses whether working conditions have improved and whether nurses and doctors welcome such decisions. Upon such suspicions, my concluding thoughts stem from R.A.W Rhodes comments upon new modes of governance, which suggests that ‘by using markets to deliver public services, bypassing existing networks and curtailing the ‘privileges’ of professions… these corporate management and marketization reforms had unintended consequences’ . Rhodes talks about how such practices (Under Margaret Thatcher) ‘fragmented the systems for delivering public services and created pressures for organizations to cooperate with one another to deliver services’ . From this, issues of trust also emerge, as I feel the public will become disillusioned with the NHS, if and when private companies and competition reign supreme. This stems from the profit driven nature of private competition, where I feel many people see a spread of networks undermining the true nature of the NHS, which above all is to provide care and enable trust within the wider public and the British government.