Merry christmas and happy new year 2020

photo: Jordi Soldevila 2020
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poverty and health

Michaela Benzeval et al. published in 2014 in The Joseph Rowntree Foundation the report How does money influence health?

The study explores the association between income and health throughout the life course and within families. Researchers reviewed theories from 272 wide-ranging papers, most of which examined the complex interactions between people’s income and their health throughout their lives.

The research identifies four main ways money affects people’s wellbeing:

1. Material: Money buys goods and services that improve health. The more money families have, the better the goods they can buy.
2. Psychosocial: Managing on a low income is stressful. Comparing oneself to others and feeling at the bottom of the social ladder can be distressing, which can lead to biochemical changes in the body, eventually causing ill health.
3. Behavioural: For various reasons, people on low incomes are more likely to adopt unhealthy behaviours – smoking and drinking, for example – while those on higher incomes are more able to afford healthier lifestyles.
4. Reverse causation (poor health leads to low income): Health may affect income by preventing people from taking paid employment. Childhood health may also affect educational outcomes, limiting job opportunities and potential earnings.

These pathways are all likely to be important and interact across people’s lives in a complex web of links between income and health. The broader context is also important. Living on a low income in a country with a well-developed welfare state is unlikely to have the same health-damaging effects as living in one with poorer provision for healthcare and education.

Given this complexity of interconnection between people’s income and health, a broad approach to improving the health of those with limited resources is important.
Acces full report

photo: Toni Catany

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healthcare organisations struggling to improve quality

Identifying characteristics associated with struggling healthcare organisations may help inform improvement.

The article published in BMJ Quality and Safety in july 2018 is a systematic reveiw of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined "by below-average performance in patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators)".

33 articles from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis.

Five domains characterised struggling healthcare organisations: 

1. Poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), 
2. Inadequate infrastructure (limited quality improvement, staffing, information technology or resources), 
3. Lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), 
4. System shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), 
5. Dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

Many characteristics shared by struggling organisations were counter to characteristics associated with high-performing organisations. For example, while disconnected leaders and non-collaborative environments were frequently found in struggling organisations, engaged leadership and a collaborative organisational culture are associated with high performance. Furthermore, a ‘flat’ or team-based approach to problems is often associated with high performance, whereas they found hierarchical culture in struggling organisations.

System shocks’ was a domain unique to struggling organisations. Although not all change necessarily causes disruption, being unprepared or unrealistic about the effort required can demotivate and anger staff. To prevent disastrous consequences, shocks must be anticipated and addressed. When shocks cannot be anticipated, leaders may directly address shocks to reduce negative consequences and potentially create positive change.

The study has important implications. The findings suggest that health systems preparing for large-scale organisational change should adequately prepare in order to prevent system shocks, which, counterintuitively, may impede change. Also the study underscores the importance of context, organisational climate and related factors in determining hospital performance. 

Open access article: Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies (2019)

photographer: Leopoldo Pomés (1931-2019). Foto Colectània 
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a good place to work

It’s not uncommon to hear people assert that it’s a bad idea to promote an engineer to lead other engineers, or an editor to lead other editors. A good manager doesn’t need technical expertise, this argument goes, but rather, a mix of qualities like charisma, organizational skills, and emotional intelligence.

Andrew Oswald, Benjamin Artz and Amanda Goodall published some articles about how workers are affected by their boss’s technical competence.

They found that employees are far happier when they are led by people with deep expertise in the core activity of the business. These results support the claim that both competence – linked to expert knowledge – and industry experience improve workers’ job satisfaction.

Access to the articles (pdf)

• If Your Boss Could Do Your Job, You're More Likely to Be Happy at Work (2016)
• Boss Competence and Worker Well-being (2014)

Another interesting articles and a video:

• Benefits of laughing
• Miguel Ángel Máñez Ortiz. Felicidad en el trabajo: truco o trato
• Humor in healthcare | Gary Edwards | TEDxBrno (video)

Have a nice summer.

photo: 1925 Life
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The CEOs in the NHS

Katharina Janke, Carol Propper* and Raffaella Sadum published in may 2019 a working paper where they investigate whether top managers affect the performance of large public sector organizations. The study examined CEOs of English public hospitals, which are large, complex organizations with multi-million turnover. They studied the impact of individual CEOs on a wide set of measures of hospital performance, intermediate operational outcomes and inputs.

Findings: "There is little evidence that individual CEOs have an impact on a large set of measures of hospital performance".

There are some possible explanations for their findings.

• The first is public sector-specific. The public sector nature of the NHS wich distort the effort of ther NHS CEOs to pursuit of political targets rather than performance-enhacing policies. The NHS is central in political discourse in the UK. Its importance means that politicians are very concerned about NHS performance, particularly negative performance, and are also keen to be seen to be doing something, which is generally manifest in a desire to implement new policies. The lack of persistent CEO effects is consistent with a scenario in which top managers simply chase political goals, rather than policies that might actually improve hospital performance. In this context, the rational response of a NHS CEO is not necessarily to improve the long-term performance of the hospital but, instead, to minimizethe amount of bad news that ends up on the Secretary of State’s desk. 
• A second explanation is that hospitals are large complex organizations, in which highly trained (and hard to monitor) individuals run separate but interconnected production processes. Management at the very top of such organizations may find it difficult to engage in coordination and getting a large number of actors, who traditionally have not worked together, to work cooperatively. The organizational inertia of a large hospital is too strong for a single manager – even if this person is the CEO – to be able to impact performance within the short time period in which they are in office, and consistently across organizations. This situation, of course, is not specific to public sector hospitals. But it may have more of an effect in hospitals, public or private, where there are many dimensions of performance (clinical, access, financial) that can be pursued and can in the short run conflict. This inertia may also be exacerbated by the often much longer contract durations of clinical staff relative to CEOs.
• The short tenure of CEOS (around 3.5 years) in the NHS may dampen their ability to systematically impress their mark in the organization they lead. A leading NHS manager recently argued that it takes five years for a CEO to make a difference but the average time in post is much shorter than that.
• The management capabilities of middle managers inhospitals are systematically associated with better outcomes. The authors suggest that rather than seeking to rapidly change hospital performance through the appointment of a cadre of “superheads”, strategies for improvement should instead focus on nurturing and sustaining the skills of middle managers.

Paper: CEOs-NHS working paper (2019, pdf)

*Carol Propper will be next friday the 14th in the plenary session of the XXIX Jornadas de Economía de la Salud  presenting this study

photo: Anna de Jaume Plensa, Monestir de Montserrat 2019  Jordi Soldevila 
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New organisational models of primary care to meet the future needs of the NHS

The NHS in England (the same occurs in Spain) faces several future challenges for primary care, including an ageing population, increasing numbers of patients with multiple long-term conditions and a limited workforce. The Health Education England Primary Care Workforce Commission  set out to identify innovative models of primary care that will meet these future challenges.

RAND Europe was commissioned in 2015 to present a brief overview of reports from professional bodies and policy-focused organisations — from England and internationally — that describe new models for delivering primary care. These models include:

• Models that introduce new roles, or change existing roles, in general practice (e.g. introducing physician associates and pharmacists into general practice, extending roles for allied health professionals and primary care nurses);

• Models of collaboration among professionals and among the primary care, secondary care and social care sectors (e.g. 'micro-teams', GPs and specialists working together and/or specialists working in the community, extended roles for community pharmacists); and
• New organisational forms for general practice (e.g. primary care federations or networks, super-practices, regional multipractice organisations, community health organisations, polyclinics and multispecialty community providers).

The review concluded that there is no ‘one size fits all’ model for delivering primary care and that the way in which changes are implemented may be as important as the model of change itself. Although several cross-cutting principles of good practice were identified. These are design principles from delivering primary care adapted from Smith et al. (2013)

• Entry to the system: patients should be able to speak to a senior health professional as early as possible and both within and out of hours.
• Specialists and generalists: there is a range of ways in which specialists and generalists could work more effectively together. Patients should have the minimum number of separate visits and consultations that are necessary, with access to specialist advice in appropriate locations
• Continuity and access: patients should be offered continuity of relationship where this is important, and access at the right time when it is required.
• Anticipatory and multidisciplinary care: care should be proactive and population-based where possible, especially in relation to long-term conditions.
• Multimorbidity: care for frail people with multimorbidity should be tailored to the individual needs of patients, in particular for people in residential care or nursing homes.
• Patient self-management: where possible, patients should be supported to identify their own goals and manage their own condition(s) and care, drawing on health professional support as needed.
• Making the most of the multidisciplinary team: primary care should be delivered by a multidisciplinary team in which full use is made of all the team members’ skills.
• Patient records: there should be a single electronic patient record that is accessible by relevant organisations and that can be read and, perhaps in future be added to, by the patient.
• Quality and information: primary care organisations should use, and make publicly available in real time, information about the quality and outcomes of care.
• Organisation and management: Primary care should have professional and expert management, leadership and organisational support.

photo: Josep Guinovart (2003) El cor de l'era (on es pot aprendre com destriar el blat de la palla)
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what works in wellbeing

What Works Centre for Wellbeing is an independent organisation from UK that produce robust, relevant and accessible evidence on wellbeing.

• They define the wellbeing concept as a way to understand what’s needed and how best we can all work together to improve our lives in a complex world. It brings together economic, social, environmental, democratic and personal outcomes and avoids focusing on specific areas at the expense of others. We can be better at measuring what matters and using what we know to create a better society. It is about engaging citizens in meaningful deliberation about what better society could look like. 

The What Works Centre for Wellbeing is part of the What Works Centre network. A What Works Centre is a bridge between knowledge and action for decision-makers.

I would like to focus on the report: Good work, wellbeing and changes in performance outcomes. This report published in december 2017 illustrates the effect of good people management with an analysis of National Health Service Trusts in England. The evidence says that the extensive use of good people‐management practices can have benefits for organisational performance and employee wellbeing.

Good people‐management practices are those which, for example:

• provide opportunities for workers to influence their work directly and allow staff to have input into decisions about their wider working environment;
• have clear roles and responsibilities for staff;
• encourage staff to communicate respectfully with each other, to collaborate, to be supportive of each other and to work effectively in their teams.
• enhance workers’ skills and support workers with access to learning and development opportunities;
• improve their motivation to perform well, provide feedback on their work through fair, accurate, supportive and effective performance management processes;
• encourage managers to support their people, through, for example, encouraging staff, giving advice and providing help with work problems.

Key findings
They found that NHS Trusts that made the most extensive use of good people‐management practices were:

• Over twice as likely to have staff with the highest levels of job satisfaction compared to NHS Trusts that made least use of these practices.
• Over three times more likely to have staff with the highest levels of engagement.
• Over four times more likely to have the most satisfied patients.
• Over three times more likely to have the lowest levels of sickness absence.
• No link was found between people management practices and patient mortality.  

Things to consider in order to introduce good people management practices

1. Review where you are at now. Is there a problem with wellbeing, absence, staff turnover or engagement? Are jobs as secure and remuneration and other benefits as good as other similar
2. Get senior management sponsorship and support for changes to people management practices. Make sure senior management buy into the idea of improvements for the sake of sustainable performance and staff wellbeing and are prepared to make the necessary commitments to make improvements in jobs. Senior managers may publically sign pledges, but also involve senior managers in project management and make regular reports to the senior management team.
3. Get support and commitment from line managers, HR and relevant management teams. Management commitment to the changes is important at all levels. Involve senior managers in getting commitment from other management groups. It might be useful to hold workshops with managers to discuss why changes are necessary, how the changes might affect them and how they will benefit. Review performance management and other people management practices to ensure managers are also supported appropriately.
4. Open a dialogue with workers about their jobs to find out what they see as important in the way they do their jobs, how they feel they are managed and how they are supported. Show workers that the changes are intended to have business and personal benefits, and that one of core values underpinning the changes is improved wellbeing. Be specific in identifying what can be changed and how to make jobs more interesting and satisfying, and look for changes that will improve wellbeing and performance. Also, gather information on who is best placed to make the changes. For example, workers themselves are often best placed to know what needs to change but they may not know how to make the changes themselves without appropriate support and training. Workshops and focus groups can be helpful to gather information, and larger organisations may find staff surveys useful.
5. Identify what needs to change and who is best placed to make the changes. Use the information from the dialogue with workers to identify what can be improved. This is also the stage to make cost‐effectiveness or return‐on‐investment projections to help choose between different courses of action. Improvements need to be feasible and acceptable to the different parties, so it is worth checking and refining plans at this stage. Check that workers have the right skills for any new roles or responsibilities and that their performance requirements are compatible with the changes. Introduce additional training and development and change other people management practices to ensure compatibility. At this stage, also decide on who is best placed to make each of the changes. This might entail a combination of groups, with staff and line managers making changes to how work is done and HR managers making changes to training, development and performance measurement/appraisal practices. Be mindful that you may need to make changes to other practices. Be sure that the changes will not work against other businesses processes and practices. For example, this could be the case if an organisation allows people the chance to use more intellectual skills and to take decisions that affect their work, yet management information systems restrict access to relevant information.
6. Once you have identified what needs to be done, the changes need to be made. To do so, empower and support those best placed to make the changes. Make sure there is a level of accountability for making the changes. This means that there should be regular, timely and appropriate feedback on how the changes are progressing given to all concerned including senior managers.
7. Therefore, at the same time, monitor, evaluate, review and revise the changes if necessary – are they delivering wellbeing and other business benefits? Are the changes sticking? What could be done to improve implementation? Through reviewing, revising and monitoring, it is possible to build a continuous improvement cycle so that initial improvements to jobs, performance and wellbeing can lead to cumulative improvements in jobs, performance and wellbeing over time as workers and managers gain more knowledge, capabilities and confidence in making incremental improvements in their work areas. In some organisations it may be possible to introduce changes in one area to see if changes are working, and then take lessons learnt to introduce changes in another area a few months after the initial changes have had chance to bed down.

photo: Jaume Plensa the Heart of Trees, Installation view at Yorkshire Sculpture Park, Wakefield, UK 2011 
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The Spanish National Health Service: chinese porcelain

 

The principles and goals of the Spanish National Health System focus on universality, free access, equity and fairness of financing. The evolution of performance measures over the last decade shows the resilience of the health system to the recent economic crisis. In terms of mortality and self perceived health it does not seem to have affected heavily at least in the sort term, although some structural reforms may be required in the medium and long term, specially to avoid the increasing income inequality, poverty, and risk of social exclusions that worsen the health indicators.

Here we have some ligth about some policy iniciatives and reforms that experts said should be adressed in the Spanish National Health System

• Cuadernos Económicos de ICE  scientific journal edited by the Secretariat of State for Trade (Government of Spain) since 1977. The current issue published in january 2019. Eight articles written by well known researchers from health economics and public health reviewing these hot topics: 

1. The arrival of new technologies with innovative mechanisms and health financing decisions.
2. Areas of public-private collaboration in health systems. focusing on continuing medical education, health research and health care management.
3. The healthcare management, its quality and the consideration of the impact of this quality on health outcomes.
4. The hospital expenditure and hospitalization evolution in the Spanish National Health System (SNS), during the period 2004-2009 and 2010-2015, analyzing their trends and medical practice variability between health areas.
5. Coordination between the health care system and the long-term care system.
6. Public health go beyond the performance of health care services. Health problems are global and require actions at a global level.
7. Good governance is a prerequisite for changing the health policy and the design of the National Health System in the right direction. Good governance in terms of: prioritization, comprehensive health policy, leadership, national health agency, and cultural and intellectual environment.
8. Economic crisis and health: lessons learned and recommendations for the future,

  Acces Full issue (pdf)  CICE Issue (2018)

• The European Observatory on Health Systems and Policies released a new health system review (HiT) on Spain.

Acces (pdf) Spain HiT (2018)

photo: "Homeless", 2005. google search words: name of the 25th richest people in the world in 2004 by Forbes (Joan Fontcuberta)  
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