tales of the expected: a case-study in health service management

So<. Ser. Mrd. Vol. 16, pp. 1801 10 1806. 1982

Printed m Great Britain

TALES OF THE EXPECTED

0277-9536 82 2OlXOI-OhSO3.00 0

Pergamon Press Ltd

A CASE-STUDY IN HEALTH SERVICE MANAGEMENT

NICK BLACK

Department of Community Medicine, University of Oxford. Radcliffe Infirmary, Oxford OX2 6HE. England

AbstractmPScientific approaches, such as operational research and health economics. have falled to resolve many of the problems confronting managers of health services. This is partly because of assump- tions about the value-free nature of information and partly through paying little regard to power conflicts in care systems. The case-study method offers a means of understanding some aspects of these conflicts. and could therefore improve the effectiveness of scientific methods in influencing decisions. An example of a case-study involving permatal care in an English health district is described in an attempt to demonstrate the practical benefits that could accrue to managers hoping to see their macro-study findings effecting change.

Management of the National Health Service (NHS) in Britain has faced disagreements and disputes at all managerial levels since its inception in 1948. The introduction of multi-disciplinary corporate management in 1974 has failed to resolve many of the medi- c+political wranglings which affect the smooth run- ning of the service. The growth of professionalism in para-medical workers, the increased industrial power of non-medical staff and the rise of a strong consumer interest in health care have expanded the number of ‘interested’ voices to be acknowledged. Some of the conflicts have been inevitable, but others have resulted from a lack of awareness and understanding of these different interests and a reluctance to aban- don longheld belief in the face of critical evidence.

The intention of management reorganisation in 1974 was to integrate the various aspects of health services to permit co-ordinated planning in relation to the needs of the people to be served [I]. Within this framework, the achievement of more uniform national standards of care in conjunction with the rapid implementation of improved approaches to health care, were to be sought. Such aims were seen to require the further development of the newly acquired sophisticated scientific means available to managers. for example. operational research, centralised information systems and health economics. These activities have attempted to resolve conflict through the study of such macro-aspects as populations. trends. policies and budgets. In addition, management science has sought to show managers how to apply successfully such skills in adverse circumstances.

Within such a structure, one of the duties of the District Community Physician (now renamed the Dis- trict Medical Officer), was to co-ordinate the planning of services at District level. including carrying out special studies for the District Management Team [2]. The Community Physician, trained in statistics and epidemiology. health economics and medical sociology. social administration and environmental health, was to bring this broad-based scientific out-

look to bear on health service issues. with an impar- tiality unique amongst hisiher specialised medical colleagues.

However, for all this well-intentioned activity. the difficulties remain. Information-dominated scientific management has not coped in practice for a number of reasons. It tends to assume that data and information are value-free and to ignore some of the inevitable conflicts between different interests in the health field. On stumbling upon these difficulties. the theory has often been abandoned and management has returned to crisis intervention and muddling through. The realisation that “change does not come through numbers alone” and “words are more important” has gained some recognition in community medicine recently [3]. Managers need, therefore, an understanding not only of the value of scientific methods, but also of the beliefs and attitudes of the interested parties involved. The acquisition of such knowledge should result in more efficient and appropriate use of the scientific methods at management’s disposal.

One way in which the essential background understanding may be obtained is through case-studies of particular issues-a methodological approach whose origins lie in the clinical medical tradition. It is based on the supposition that some important knowledge of a phenomenon can be derived from ‘.the intense ex- ploration of a single case”. and as such has also been widely adopted by the social sciences 141. It is of particular value in the identification of orgamsational problems and in finding their origins and conse- quences at various levels and in various parts of the system. as for instance in Goffman’s work [5].

An example of such a study is described here in an attempt to demonstrate the sort of aspects which may

be gained from attention to detail. The background to the issue is first described along with how the story unfolded. Attention is then focused on the underlying conflicts that affected the action and outcome. and some comments on what may be gained from this type of analysis-both specifically about this subject. and generally about management of health services.

1802 NICK BLACK

THE ISSt’E

In the field of maternity care, there are contentious issues involved in aspects of the services provided. the processes of care and measurements of outcome. There is much debate about the relative desirabilities of deliveries at home. in General Practitioner Mater- nity Units (GPUs) [6] and in consultant obstetric units [7]. Controversy extends to the processes of care-induction of labour. foetal heart monitoring, Casarean section, neonatal intensive care -and also to the interpretation of outcome, such as perinatal mortality and morbidity, and mother child bonding. The story described below concerns the maternity services for one particular Health District. Superficially the issue was perinatal mortality, but analysis of the plot revealed that many of these other factors were also involved (e.g. place of delivery. levels of obstetric intervention).

The Health District has two consultant maternity units. each with several allied General Practitioner Units. In the Western part of the district lies West City. served by a large maternity hospital with both intensive and special care neonatal facilities. Almost 90”,, of deliveries in this part of the District take place in the consultant obstetric unit of this hospital, with the remaining IO”,,, in the four GPUs (and a few at home). The proportions represent the result of a con- tinuing District policy of reducing the number of deliveries outside the consultant unit. This is illustrated by the fact that the continued existence of the remaining GP maternity beds were under threat during the period to which this case-study refers.

In contrast. in the Eastern part of the District lies East Town. with a small District General Hospital (DGH) which handles only 57”,, of the deliveries in its catchment population the other 43”,, deliver in either one of the four local GPUs or at home. The consultant unit in the DGH provides less specialised obstetric and paediatric facilities than the unit in West City. though it does have a special care baby unit.

Each year. the Regional Health Authority (RHA) [8] in which the district lies. publishes statistics for each hospital. These include the crude perinatal mortality rate (PNMR) 197 for each place of delivery. In 197X. the rate for the consultant unit in East Town was twice that of West City, a fact that was noticed by the Community Health Council (CHC) [IO]. They approached the District Management Team (DMT) for an explanation of this apparently disturbing state of affairs.

The Obstetricians in East Town. when commenting on this finding pointed out several factors that needed to be taken into account when interpreting the crude PNMR. These included the uncertainity of intcrpret- ing one year’s statistics, particularly as their unit only managed about 1000 births a year: the fact that most of the few deaths that had occurred were due to un- avoidable factors- such as major congenital abnor- malities; and the high proportion of GPU deliveries in their area. which left the consultant unit with a high proportion of potentially difficult deliveries.

However, these comments plus a visit to the consultant unit in East Town, failed to allay the fears of the CHC who continued to press for further enquiries and studies to be made. This was resisted by the Obstetricians who were becoming increasingly concerned with what they saw as a concerted attack on their unit. The conflict was further fueled by an article in the local press, By then battle lines had been drawn. and each side was quoting different statistics. or the same statistics with different interpretations. in support of their argument.

In an attempt to offer a more detailed assessment of the relative achievements of the two consultant units, an epidemiological study of the mortaility experiences over the years 197@~1978 was carried out by the Community Physicians, The data that had initially alarmed the CHC was the crude PNMR for the consultant unit in East Town in 197X. Due to the rela- tively small number of deliveries annually in this unit. the rates showed considerable year to year fluctu- ation. The crude rates had been following the general decline experienced by England and Wales as awhole though West Citv was usuallv lower than East Town. ConGdering the iery differen; proportions of GP deliveries in the two areas, the first adjustment required was a consideration of the fortunes of women deliver- ing in-and-around East Town with those in-and- around West City. In other words combine the data for the consultant unit and GPUs in each catchmcnt population. The crude PNMRs then showed no slg- nificant differences supporting the belief of the East Town Obstetricians that West City experienced a dilution by large numbers of low risk deliveries who were being confined by GPs in East Town. However this was still a comparison of crude rates.

The two most significant determinants of perinatal outcome are the presence of lethal congenital malfor- mations and birthweight [I 11. By first removing any perinatal deaths which were caused by lethal malfor- mations (for which it is not expected that health services can successfully intervene) and then calculating

Table I. Birthweight-specific adjusted PNMRs per 1000 total births (actual numbers in parentheses)

Birthweight

I500 g and belo%

1501 25oog

over 7500 g

1973-197s 1976 -1978 Oxford Banbury Oxford Banbury

464 615 317 444

(70) (16) (44) (8) 54.0 60.6 43 7 60.4

(46) (12) (36) (9) 2.98 4.1 I 2.54 7.53

(411 (20) (35) (10)

Tales of the expected 1803

PNMRs for specific birthweight categories. it was possible to arrive at a more meaningful measure of the performance of services in East Town and West City. This demonstrated (Table 1) that there was no statistically significant difference in the birthweight specific PNMRs experienced by the two catchment populations (East Town and West City) during the most recent years 19761978 (though prior to this West City had experienced lower PNMRs than East Town). Armed with this information, the CHC felt able to reassure the community in East Town that the mortality outcome of pregnancies delivered in their locality was the same as that in the rest of the Dis- trict. However, the study had in effect demonstrated that the sophisticated obstetric care provided for the majority of deliveries in West City, did not signifi- cantly improve perinatal outcome. at least in terms of mortality.

Copies of the report were sent for comment to the obstetric and paediatric consultant staff of both units and to the DMT. During the ensuing few months, the DMT drew up plans to continue the closure of GPU facilities around West City which would have the effect of further increasing the proportion of consultant unit deliveries.

BACKGROUND HISTORIES

The value of a case-study such as this is derived from an analysis of the apparent motives and attitudes determining the behaviour of the protagonists. No one person can be party to all such knowledge, so what follows is simply an attempt to offer some expla- nations of why the plot unfolded the way it did.

(i) Thr CHC

Any CHC’s relationship to a Health Authority and DMT will be determined to some extent by its experiences in all aspects of the District’s services. In this instance, the preceding months had seen disagreements over both hospital closures and resource allocation to services for the elderly and the disabled. The CHC had little confidence in the management team’s ability to provide adequate services whilst avoiding over-spending. In their secretary’s view the problems lay in incompetent management rather than in the fact that the District had been not only unfavourably affected by the introduction of RAWP, but also by the lack of any additional resources to open a major new capital scheme.

When the statistics on PNMRs first appeared, the CHC were already concerned about obstetric services in and around East Town. They had received letters from women complaining of miserable experiences in the consultant unit. and had taken the step of encouraging other women who had been unhappy with their treatment there to register their complaints. In addition, there had been a long standing antipathy towards the consultant obstetricians over their attitude to abortion. Women requesting a termination had to travel to West City or to private facilities outside the District-another issue in which the management team and Health Authority had apparently failed to meet the needs of their population.

West City maternity hospital had also failed to

meet the ideals of the CHC which wanted to see not only good perinatal outcome but also a low rate of obstetric intervention. The unit’s increasing consump- tion of resources for maternity services and the need to maintain an adequate throughput of cases had led to a major reduction in GPU deliveries-a development which the Health Authority seemed unable or unwilling to prevent. The CHC was also uneasy about some of the life-saving activities of the neonatal intensive care facilities, particularly regarding the long term outcomes-a concern shared by some paediatric and obstetric staff in East Town. For all that, West City Obstetric Unit had received much praise from national consumer groups for its pattern and standard of care, a factor which brought into question how representative of consumer opinion the CHC’s views were on this issue. The CHC were apparently presented by the Obstetricians with the choice of either safer delivery with high levels of intervention. or less intervention with increased attendant risks. Such a choice, whilst sincerely believed by the obstetricians, finds little support from research studies into the effects of intervention. Indeed, some obstetric practice leads to iatrogenic problems, such as increased Caesarian section rates and more admissions of infants to special care baby units.

In summary, the CHC’s concern over apparent obstetric failures in East Town was being met with the answer that more consultant unit deliveries, with all the attendant intervention, was the way forward. However, this was an approach with which they were equally concerned. They were thus experiencing diffi- culty in presenting a consistent attitude to maternity care, partly due to the inadequacy of their own analysis and partly the lack of help from elsewhere. such as community medicine.

(ii) The Health Authority and District Managernext Team

Just as the CHC’s view of the Health Authority and DMT was based on dealings stretching back over several years, so the Health Authority and DMT had developed particular approaches to the CHC. The managers of the District (not just the management team, but middle management as well) saw the CHC as a chronic irritant, which at times became a particularly disruptive force. There seemed to be acceptance of the CHC as the representative of consumer opinion, but annoyance when such a role led to inter- ruption of management strategies. This had been most obvious during hospital closure negotiations when CHC appeals against a closure had delayed the implementation of plans designed to improve hospital facilities in the District.

The Authority’s strategic plans for maternity services based on national guidelines, involved a steady transfer of deliveries from GPUs to consultant units-a policy they had been successfully carrying out for several years. Any evidence questionning the value of such a policy was clearly going to provoke conflict. Thus the management attitude on PNMRs seemed to be that the CHC had yet again missed the point and failed to understand the complexities of the issue. In addition, management may have seen the CHC’s action as another attempt to cause them embarrassment.

I x04 NICK BLACK

However, for all the overt signs of disagreement between the CHC and DMT, it seemed that on many issues some members of the management team may have shared some of the CHC’s views and criticisms. but felt the need to defend the services for which they were responsible. This conflict arises because the DMT cannot interfere with the clinical freedom of the consultants. who are thcrcfore able to determine the relative proportions of GPU and consultant unit deliveries. Thus decision on service provision rests with the clinical autonomy of the consultants and not with management a situation publicly acknowledged by the Vice-Chairman of the Health Authority.

In addition. there were other internal management difticulties. The area in and around East Town con- tains less than a fifth of the district population, which has always felt disadvantaged compared to the larger population of the West City area, with its prestigious modern hospital. This had led to calls for the creation of an East Town District. in the belief this would result in more resources and a better deal for the local population. This was a view shared by many. though by no means all health service staff and CHC members from that area.

The Authority also had to contend with the opinions of the West City consultants. and was well aware that the development of services in their large new unit had had the effect of draining resources away from the small GPUs. This had resulted in the demise of the GPUs which were now under threat of closure on the grounds of reduced throughput. Any attempt by the Health Authority to meet the demands of East Town by shifting resources from West City would have been strongly resisted by the West City Obstetricians who would have argued that they required more. rather than less, resources themselves.

Some months after the CHC’s first enquiry about PNMR in the East Town Unit, one of the obstetricians there was quoted in a local paper as saying “We can stand up and say we have one of the best. if not the best record in the country”. He went on to invite a local CHC member, who had called for an inquiry. to contact him. so that he could prove it. This overtly conciliatory stance by the consultants, concealed a private irritation at what they saw as a concerted campaign by the CHC to vilify their unit. In reply to the charge that local women were unhappy with the service they provided. they cited the 293 letters of commendation they had received the previous year from satisfied patients. Their experience of the CHC had led one of the obstetricians to favour its disband- ment: not only hc thought. had it deliberately mis- represented the position. but it was also an unnecess- ary waste of resources.

East Town’s feelings of isolation and receiving in- adequate attention arose primarily from the twenty miles separating them from the large West City hospital and were compounded by the pattern of management. The management team rarely met outside West City. and in addition East Town consultants felt they were unrepresented at all levels of decision-making and policy formation. In consequence they felt de- prived of both resources and attention to their problems. One such example was the lack of support the

single-handed consultant paedlatrician received from his specialist colleagues in West City. This kvas seen as evidence of the unfair resource allocation even though in fact the number of medical staff per delivery in East Town was higher than in the supposedly ‘over-staffed’ West City, because of the inevitable dis- economy of any small unit.

East Town’s consultants’ opinions of their West City colleagues was not confined to relative stalling and resource levels. They were privately critical of the pattern of care provided in West City where, like the CHC. they considered too much intervention occurred. and too much effort was put into the preser- vation of neonatal life at any cost. There was a belief that this latter policy was detrimental in increasing the incidence of handicapped survivors.

(iv) M’cst Cifj, c~orf,51r/tar1t.s

In contrast to their colleagues in East Town. the consultants in West City felt secure in the knowledge that they could attract the attention of the Health Authority. In the past they had been able to dcvclop their specialist service at the expense of the GPUs. The only opposition to this trend had come from local resldcnt groups and the CHC. campaigning for the survival of the GPUs. The sllggestion that CPU deliveries for selected mothers were as safe as consultant unit deliveries was rejected by the consultants as ‘mischievous’. Any apparent difercncc in PNMRs between their unit and that in East Town was of no

surprise to them. since they claimed they provided a higher standard of care. including special clinics for high-risk mothers.

THE RESPONSE TO THE EUQL IR\

The publication of the results of the study by the Community Physicians into PNMRs met with a mixed response. The study showed that the mortality rates for each birthweight group did not differ signiti- cantly between the two parts of the district. The CHC. who had pressed for the study. accepted that the analysis of perinatal mortality did not support their criticism of the East Town Unit. However this did little to defuse their pressure for changes based on the information they had received from individual com- plainants.

On the other hand. the obstetricians in East Town felt vindicated. Their conviction that the scrvicc they provided was ‘second to none’ may not have been demonstrated. but at least their outcome in terms of perinatal mortality could be seen to be as good as that of their ncighbours in West Citv. Not only that. but this was achieved with 43”,, of deiileries in GPUs, whereas the West City area only had lo”,, of such deliveries and more sophisticated hospital technology. Their Obstetric colleagues in West City did not re- spond to the report.

One group which did show interest and a desire to discuss the findings was the West City paediatricians. They appeared to resent the ‘poaching’ by the Com- munity Physicians of an activity which they considered to be theirs. This arose through their view of the role of community medicine, which appeared not to include that of monitoring health services. Implicit in their resentment was the consideration that only

Tales of the expected 1805

the service providers are in a position to assess the value of each aspect of health care, as only they are able to understand the complexities and nuances involved. In the event, the paediatricians comments were confined to methodological criticisms rather than any comment on the findings.

The management team offered no response to the report. This may reflect their over-concern with finan- cial book balancing rather than with what the money purchases and the effectiveness of the services pro- vded. Their failure to react did little to improve the CHC view of local management and this inactivity provided the CHC with a further opportunity to question the District’s policy on maternity services.

CONCL.LSIONS

It is unrealistic to expect a single case-study, such as this one. to demonstrate. describe and discover all the factors that atlect the management of a Health District. It is necessary to focus on the issues that appear to be of major importance.

In this study three such issues emerge. The first is the difference between private (as confided in the ob- server) and public opinions. This was true of several relationships the DMT and the CHC; the DMT and the consultants of both units; the CHC and the East Town consultants. Thus the East Town consultants privately harboured resentment about the very existence of the CHC, whilst publicly inviting them for discussions and a visit to their unit. Similarly, the Health Authority recognised that the West City consultant unit was draining resources away from the GPUs. but only expressed such a view in private discussions. Such differences are presumably the inevitable consequence of political expediency. as forth- right honest public communication would result in a collapse of any dialogue between the opposing fac- tions. However. this does present management with considerable problems in achieving one of their objec- tives. namely the improvement of communication between different sections of the service. To what extent does the deliberate drawing together of diverse interested parties lead to greater mutual understanding or to a hardening of differing opinions and views‘? If the latter is the case, then management may need to pursue other methods for reconciling conflicting interests.

A second issue is the way in which individual issues are handled within the framework of existing relationships and power structures. Thus the DMT’s reception of the CHC enquiry about PNMRs was coloured by previous encounters over such topics as hospital closures. as was the CHC’s reception of the East Town PNMRs affected by issues such as the provision of abortion services. These are dangers in a ‘fragmented’ management approach where each issue is tackled in isolation rather than within the historical and structural framework of the complete service.

The third issue concerns the response of different groups to information. i.e. the way in which people decide what to accept and reject. There appeared to be four different reactions to unwelcome information. The first. demonstrated by the West City paediatricians. was to challenge its correctness or appropriate- ness. Thus information was rejected by suggesting the

methodology was suspect or the statistical technique inappropriate. This avoided having to make any specific response to the findings. The second reaction was to declare that the information was irrelevant to the ‘real problem’. and that the wrong question had been answered. This was employed by the East Town Obstetricians in response to the initial approach of the CHC and by the CHC when they received a reply from the consultants.

The third response involved accepting the information supplied, but denying that it constituted any reason to change policy. This can be done either by citing alternative conflicting evidence. or by justifying the findings with practical reasons. as to why change is undesirable and!or impractical. As Gray and Morris [3] have noted. “either side can use selected observations to refute the other’s theory”. The fourth response, simply to ignore the information, was demonstrated by the management team and West City Obstetricians. This response appeared to be the pre- rogative of the more powerful groups. whereas other groups responded in the ways outlined above.

The uncertainty of these interpretations based as they are on a single study. underlines the need for more such case-studies of health service management. for it suggests a number of questions. Is the group response to the sort of information provided by quan- titive scientific techniques. such as operational research. and the ability to inflict that response determined solely by the power the group possesses? Is professional status within medicine the main determinant’? Is there a pattern to the responses, to the extent that difficulties can be predicted and maybe avoided and that this should be an essential role of management‘? Do CHCs have a feasible role’? Without an understanding of these issues. the rational objec- tives of scientific approaches will not be achieved.

The case-study method beloved and respected within clinical medicine. needs to be adopted by medical and non-medical colleagues in management. It must therefore be incorporated in management research and training. alongside the other established approaches. In many ways case-study analysis is a natural activity of all effective managers. and represents a learning resource that is at present under- valued and little used. For instance. community medicine training emphasises quantitative scientific methods and pays only scant attention to the sort of information which can be obtained from case-studies. A single case-study such as this can only lead to ten- tative conclusions which require further study by the analysis of different subjects and in different places. By encouraging practitioners of the art of successful management to pass on their skills through storytell- ing. those wishing to become effective managers could benefit. whilst others could understand why the best of all possible worlds remains, as yet. beyond our grasp.

A~know/rdyc,n1c,r2r,s~l should like to thank Dr Sheila Adam. Dr lain Chalmers. Dr Alex Gatherer. Dr Harry McNeilly. Linnie Price. Phil Strong. Professor Martin Ves- sey and Dr Graham Winyard for their helpful comments on earlier drafts and Sylvia Jones and Pam Hughes for typing the paper. In addition I thank the clinicians. managers. Health Authority members and the CHC for taking the time to discuss the issues involved in this paper.

I806 NICK BLACK

Observational studies of this kind can be used to embar- rass individuals or endanger the organisation studied. It has been the intention of this paper to avoid such undesirable effects. and to that end I hope it has been successful.

7.

REFERENCES 8

1.

2.

3.

4.

5. 6.

DHSS. Mtmuycment Arranyrmrnts fiw the Rroryunkd Natunml Health Serricu. HMSO. London, 1972. District Management Team (DMT) consists of the four executive officers of the District along with representa- tives of the hospital doctors and General Practitioners (usually one of each). The DMT is responsible for the day-to-day management of the District, though ulti- mate responsibility at District level resides with the Health Authority (a lay body with some health pro- fcssional representation). 9. Muir Gray J. A. and Morris R. The words-numbers continum. Conlmunir. Med. I, 243-247. 1979. Becker H. S. Socioloyicul Work. Mc,rhod und Suhstunce. 10. Transaction Books, New Brunswick. 1970. Goffman E. Asylums. Aldine, Chicago. 1961. General Practiiioner Maternity Umts (GPUs) are obstetric beds staffed by General Practitioners and mid- wives and are used for ante-natal. intrapartum and I I post-natal care. The units may be on the same site as a

Consultant Obstetric Unit (so-called ‘integrated CPU’) or part of a small General Practitioner or Community Hospital (an ‘isolated GPU’) some distance from specialist obstetric care. Both types of unit existed in the Health District in question. Kitzinger S. and Davis J. A. (Eds) T/W PItice of Birth. Oxford University Press. Oxford. 1978. Regional Health Authority (RHA) is the body that is responsible for providing services for an Enghsh Region containing a population of between 2 and 5.5 million. Among its respdnsibilities is the monitoring of the Health Districts within its area. The latter have populations of between 80.000 and 600.000 and it is intended that each Health District should be responsible for providing most general hospital and community services. Some districts. such as the one in this study. have more than one District General Hospital. Perinatal mortality rate (PNMR) is the number of stillbirths plus deaths during the first seven days of life per 1000 total births (livebirths plus stillbirths). Community Health Council (CHC) is the body which represents the interests and views of the consumers of health care. They receive a modest budget from then local Health District and are a statutory requirement of all Districts. Chalmers I. The search for Indices. Lrr~c,f ii, 1063~1065. 1979.

tales of the expected: a case-study in health service management

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