Counting the costs: The risks of regulating and accounting for health care provision

Abstract

Payment by Results (PbR) is one of the most fundamental changes in NHS policy since the introduction of the 'internal market' in 1991. It is also one of the most visible and influential attempts across the same period to modernize the NHS through accounting and, more specifically, costing. As a funding system, PbR promises to pay providers fairly and transparently by using a 'standard national tariff.' However, like all accounting based reforms, PbR encounters the range of professions and expertises active in the domain. Like all costing systems that give visibility where previously it was lacking, PbR creates new calculable spaces and new risks. The aim of the paper is threefold. First, we seek to chart the nature of the arena within which PbR operates. We identify the multiple actors that are influential in the regulatory field of health service provision, and focus on three types of actor in particular, namely the National Institute for Health and Clinical Excellence (NICE), Monitor and professional medical associations. We argue that these three actors need to be viewed as representative of different types of expertise (schematically speaking, health economics, accounting and medicine) and that, to understand fully the nature of the regulatory game in the healthcare arena, PbR needs to be analysed not as a stand alone intervention but as enmeshed within the inter-professional complex that emerges out of the interaction of these three types of expertise. Second, we argue that we need to focus on the ways in which PbR, along with other regulatory interventions in the healthcare field, such as those of NICE and Monitor, seek to create new and sometimes competing calculable spaces based on different entity assumptions. Third, we argue that to understand empirically the dynamics of healthcare reform in the UK we need to examine the extent to which PbR creates new calculating selves, or a hybridizing of the calculating and medical self. The regulatory complex within which PbR operates may, we argue, produce contradictory incentives and thereby contribute to systemic provision risks.

When spaces collide: exploring the dual responsibilities of operations managers

“…Kurunmaki (1999) defines an accounting entity as a representational area of interest constructed to define activities, people and artifacts. In other words, space may vary depending on the actors who operate within a space (Kurunmäki and Miller, 2008). Accounting entities are given boundaries to provide clarity regarding organizational responsibilities (Kurunmaki, 1999;Carmona et al, 2002;Carmona and Ezzamel, 2009).…”

Accompagner la mort, organiser la fin de vie

“…Le chiffre devient la clé de voûte d'un édifice disciplinaire permettant une surveillance permanente, principalement des médecins et de leurs équipes (Angelé-Halgand et Garrot, 2015). Les systèmes de tarification à l'activité incitent ainsi, entre autres, à sélectionner les patients les plus rentables (Livne, 2014 ;Kurunmaki et Miller, 2008) et à « faire tourner les lits » (Belorgey, 2010 ;Kletz et Moisdon, 2015). Cependant, certaines recherches montrent que les médecins parviennent à maîtriser l'utilisation du système de mesure, voire à le manipuler à leur avantage (Georgescu et Naro, 2012), ce qui limite les possibilités de surveillance.…”

Book Review: Rejoinder to Alan McKinlay

“…For instance, Kurunmäki and Miller (2006), drawing on Kurunmäki (2004), focus precisely on this issue of 'travelling', when they consider the hybridizing of expertise and organizational forms that the 'modernizing government' agenda required and inspired. Related issues -concerning healthcare regulation and risk management, respectively -are addressed in Kurunmäki and Miller (2008) and Miller et al (2008). Mennicken (2008), in a paper titled 'connecting worlds', examines the apparently technical issue of the travelling and translation of international auditing standards into post-Soviet audit practice.…”