Department of Public Health & Policy Studies, Swansea University, UK.
BMC Health Serv Res. 2013;13 Suppl 1(Suppl 1):S7. doi: 10.1186/1472-6963-13-S1-S7. Epub 2013 May 24.
This paper examines NHS secondary care contracting in England and Wales in a period which saw increasing policy divergence between the two systems. At face value, England was making greater use of market levers and utilising harder-edged service contracts incorporating financial penalties and incentives, while Wales was retreating from the 1990 s internal market and emphasising cooperation and flexibility in the contracting process. But there were also cross-border spill-overs involving common contracting technologies and management cultures that meant that differences in on-the-ground contracting practices might be smaller than headline policy differences suggested.
The nature of real-world contracting behaviour was investigated by undertaking two qualitative case studies in England and two in Wales, each based on a local purchaser/provider network. The case studies involved ethnographic observations and interviews with staff in primary care trusts (PCTs) or local health boards (LHBs), NHS or Foundation trusts, and the overseeing Strategic Health Authority or NHS Wales regional office, as well as scrutiny of relevant documents.
Wider policy differences between the two NHS systems were reflected in differing contracting frameworks, involving regional commissioning in Wales and commissioning by either a PCT, or co-operating pair of PCTs in our English case studies, and also in different oversight arrangements by higher tiers of the service. However, long-term relationships and trust between purchasers and providers had an important role in both systems when the financial viability of organisations was at risk. In England, the study found examples where both PCTs and trusts relaxed contractual requirements to assist partners faced with deficits. In Wales, news of plans to end the purchaser/provider split meant a return to less precisely-specified block contracts and a renewed concern to build cooperation between LHB and trust staff.
The interdependency of local purchasers and providers fostered long-term relationships and co-operation that shaped contracting behaviour, just as much as the design of contracts and the presence or absence of contractual penalties and incentives. Although conflict and tensions between contracting partners sometimes surfaced in both the English and Welsh case studies, cooperative behaviour became crucial in times of trouble.
本文考察了英格兰和威尔士的国民保健制度（NHS）二级保健合同，该时期两个体系的政策分歧日益扩大。表面上看，英格兰越来越多地利用市场杠杆，采用更具挑战性的服务合同，其中包括财务处罚和激励措施，而威尔士则从 20 世纪 90 年代的内部市场后退，强调合同过程中的合作和灵活性。但也存在跨境溢出效应，涉及共同的合同技术和管理文化，这意味着实际合同实践中的差异可能比政策差异所表明的要小。
通过在英格兰和威尔士各进行两项定性案例研究，调查了实际合同行为的性质，每项研究都基于当地的采购/供应网络。案例研究包括对初级保健信托（PCT）或地方卫生委员会（LHB）、NHS 或基金会信托的工作人员进行民族志观察和访谈，以及对相关文件的审查。
两个 NHS 系统之间的更广泛政策差异反映在不同的合同框架中，涉及威尔士的区域招标和我们在英格兰案例研究中的 PCT 招标或合作的一对 PCT 招标，以及服务的更高层次的不同监督安排。然而，在组织的财务可行性受到威胁时，购买者和提供者之间的长期关系和信任在两个系统中都起着重要作用。在英格兰，研究发现了一些例子，即 PCT 和信托都放宽了合同要求，以帮助面临赤字的合作伙伴。在威尔士，有关结束采购/供应分离的计划的消息意味着恢复到不太具体的固定合同，并重新关注 LHB 和信托工作人员之间的合作。
当地采购者和提供者的相互依存关系促进了长期关系和合作，从而塑造了合同行为，就像合同的设计以及合同处罚和激励的存在或不存在一样。尽管在英格兰和威尔士的案例研究中，合同伙伴之间的冲突和紧张有时会浮出水面，但合作行为在困难时期变得至关重要。
