London School of Hygiene and Tropical Medicine, London, UK.
Soc Sci Med. 2011 Jul;73(2):185-92. doi: 10.1016/j.socscimed.2011.05.021. Epub 2011 May 30.
The use of contracts is vital to market transactions. The introduction of market reforms in health care in the U.K. and other developed countries twenty years ago meant greater use of contracts. In the U.K., health care contracting was widely researched in the 1990s. Yet, despite the changing policy context, the subject has attracted less interest in recent years. This paper seeks to fill a gap by reporting findings from a study of contracting in the English National Health Service (NHS) after the introduction of the national standard contract in 2007. By using economic and socio-legal theories and two case studies we examine the way in which the new contract was implemented in practice and the extent to which implementation conformed to policy intentions and to our theoretical predictions. Data were collected using non-participant observation of 36 contracting meetings, 24 semi-structured interviews, and analysis of documents. We found that despite efforts to introduce a more detailed ('complete') contract, in practice, purchasers and providers often reverted to a more relational style of contracting. Frequently reliance on the NHS hierarchy proved to be indispensable; in particular, formal dispute resolution was avoided and financial risk was re-allocated in compromises that sometimes ignored contractual provisions. Serious data deficiencies and shortages of skilled personnel still caused major difficulties. We conclude that contracting for health care continues to raise serious problems, which may be exacerbated by the impending transfer of responsibility to groups of general practitioners (GPs) who generally lack experience and expertise in large-scale, secondary care contracting.
合同的使用对市场交易至关重要。二十年前，英国和其他发达国家在医疗保健领域推行市场改革，导致合同的使用更加广泛。在 20 世纪 90 年代，英国广泛研究了医疗保健合同。然而，尽管政策环境发生了变化，近年来该主题的关注度却有所下降。本文通过报告 2007 年国家标准合同引入后英国国民保健制度（NHS）合同的研究结果，试图填补这一空白。本文通过使用经济和社会法律理论以及两个案例研究，考察了新合同在实践中的实施方式，以及实施与政策意图和我们的理论预测的符合程度。本文通过对 36 次合同会议的非参与观察、24 次半结构化访谈和文件分析收集数据。我们发现，尽管努力引入更详细的（“完整”）合同，但在实践中，购买方和提供方经常恢复到更具关系型的合同模式。对 NHS 层级结构的频繁依赖被证明是不可或缺的；特别是，避免了正式的争议解决，并且在妥协中重新分配了财务风险，这些妥协有时忽略了合同条款。严重的数据缺陷和熟练人员的短缺仍然造成了重大困难。我们的结论是，医疗保健合同仍然存在严重问题，而即将向缺乏大规模二级保健合同经验和专业知识的普通科医生（GP）群体转移责任，可能会使这些问题更加严重。
