Changing cultural visions in the NHS.
Vision for the NHS, mid 1980s to mid 1990s (General Management and The Internal Market) | Vision for Labour's “New NHS”, late 1990s (The Third Way) | |
Macro/system level factors | ||
Basis of economic relationships: | Competition (contracts) | Cooperation/partnership (long term service agreements) |
Governance: | Market discipline | “Third way” |
Key objectives: | Efficiency | Efficiency/equity/quality |
Rate of change: | “Big bang” | Evolutionary |
Locus of change: | Top down | “Everyone's business” |
Flows of information: | Confidential/commercially sensitive | Open/transparent |
Basis of performance assessment: | Finance/activity/volume | “Balanced scorecard” |
Micro/clinician level factors | ||
Basis of practice: | Professional judgement | Evidence based |
Basis of control: | Mutuality/trust | Audit, external verification |
Clinical performance information: | Confidential | Publicly available |
Participation in audit (e.g. confidential enquiries): | Discretionary | Mandatory |
Accountability: | Largely opaque (professional self-regulation) | Transparent: corporate and clinical governance |
Public confidence: | High | Diminished |
Continuing professional development: | Discretionary | Mandatory |
Ethical basis: | Hippocratic oath/patient first | Corporate objectives |