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Health service reform: the perceptions of medical specialists in Australia (New South Wales), the United Kingdom and New Zealand

Rod J Perkins, Keith J Petrie, Patrick G Alley, Peter C Barnes, Malcolm M Fisher and Peter J Hatfield

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Abstract - Introduction - Methods - Results - Discussion - Disclaimer of conflict of interest - References - Authors' details

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Abstract

 Objective: To examine the effect of recent healthcare service changes (including significant resource constraint and a greater role for the non-medical manager) in the United Kingdom, Australia and New Zealand on medical specialists' perceptions of their healthcare organisation goals and service delivery, and their enthusiasm for their work.
Design: Postal questionnaire survey, answered anonymously.
Participants and setting: Medical specialists employed either part- or full-time in two United Kingdom National Health Service Trusts (one acute, one mental health/community service), an Australian Area Health Service and a New Zealand Crown Health Enterprise in 1995.
Main outcome measures: Participants' rating of their knowledge of employers' organisational goals, ability to influence management, perceptions of changes in resources and service availability since 1990 and changes in enthusiasm for their work over the past four years.
Results: 369 of 521 eligible specialists responded (71%); by country -- United Kingdom, 123/186 (66%); New Zealand, 123/160 (77%); Australia, 123/175 (70%). New Zealand specialists were less aware of their employers' organisational goals and had less congruence between these and their own personal goals than United Kingdom or Australian specialists (P < 0.05). Interest in influencing central management was similar in the three countries, but Australian specialists felt management was less likely to follow their advice compared with United Kingdom specialists (P < 0.05). New Zealand specialists perceived that waiting times for non-urgent patients were currently longer than in 1990 compared to United Kingdom specialists (P = 0.02). In all three countries, inpatient beds were perceived to be less available than in 1990, but less so in New Zealand. The ease of replacing equipment was better in New Zealand than in Australia and the United Kingdom (P = 0.00001). More than 50% of participants in all three countries (183/361; 50.7%) reported that their enthusiasm for their work had decreased in the past four years.
Conclusion: The effects of health service reforms seem to have reduced enthusiasm for work among medical specialists in Australia, the United Kingdom and New Zealand.

MJA 1997; 167: 201-204  

Introduction

 In recent years, Australia, New Zealand and the United Kingdom have seen major structural changes in the way health services are funded and managed (Box 1), and these changes have altered relationships between doctors and managers.1,2 Whether the new structures deliver better services to populations -- in terms of cost, quality and access -- is currently debated, but little information is available on the impact of these changes on the working lives of specialists in hospital settings.3,4

We set out to determine whether the healthcare changes affected specialists' attitudes towards their work and practice. We assessed their perceptions of their current influence on central management, whether their enthusiasm for involvement in healthcare delivery had changed since the changes were instituted, and whether they believed that availability of resources and services to their patients had changed.  

Methods

  

Participants

 In 1995 we mailed questionnaires to 521 specialists (individuals holding College postgraduate qualifications) employed full-time or part-time in two United Kingdom National Health Service Trusts (Salford Royal Hospitals and Newcastle City Health), a New Zealand Crown Health Enterprise (Capital Coast Health, Wellington) and an Australian Area Health Service (staff specialists or visiting medical officers in the Northern Sydney Area Health Service, New South Wales). Specialists from two National Health Service Trusts were surveyed to ensure that all specialties were represented from each country. The questionnaire (to be answered anonymously) was mailed with a covering letter from a senior colleague within their organisation. A second questionnaire was sent to all specialists approximately six weeks after the first (as we did not know who replied to the first mailout, we had to send everyone a second).  

Questionnaire

 Participants were asked to rate, on seven-point Likert scales:
  • Their knowledge of their employer's goals, the congruence between what they like doing in their work and what their employer wants them to do, their interest in influencing hospital or service management, and the extent to which their advice is noted or acted upon.

  • The time spent per week in hospital management meetings (from less than one hour to more than six hours), on a scale of less than one hour, one to two hours, two to three hours, etc.

  • Their perception of changes in resource availability and service over the past four years; specifically, waiting time for non-urgent patients, availability of beds, and condition and ease of equipment replacement.

They were also asked to rate whether their enthusiasm for their work had increased, stayed the same, or decreased.

Open-ended questions (e.g., "If your enthusiasm for your work has changed in the past four years, please state why.") invited the participants to comment on the changes.  

Statistical analysis

 The results were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows.5 Non-parametric tests were used to analyse the time spent in management meetings. Differences between specialists in the three countries were assessed using one-way analysis of variance and post-hoc Tukey B tests. Differences in the specialists' enthusiasm for work were evaluated using a contingency table and the chi-squared statistic.  

Results

 Three hundred and sixty-nine replies were received after the two mailings (overall response rate, 71%). By country, response rates were: United Kingdom, 123/186 (66.0%), Australia, 123/175 (70%) and New Zealand, 123/160 (77%). Twenty-four percent of the specialists were aged under 40 years, 35% were 40-49, 23% were 50-59 and 19% were 60 years or older. Women made up 19% of the total sample and were equally represented in the three countries (chi-squared = 2.92; df = 3; P = 0.23). There were more full-time specialists in the United Kingdom (56 full-time, 27 part-time) than in New Zealand (33 and 58) and Australia (40 and 47) (chi-squared = 17.53; df = 2; P = 0.0001).  

Time in management meetings

 There was no difference between New Zealand and Australian participants in the amount of time spent in meetings about hospital or service matters (median for both, less than one hour per week; Mann-Whitney U test = 6950.5; P = 0.18). United Kingdom specialists spent significantly more time in these meetings (median, one to two hours) compared to either New Zealand (Mann-Whitney U test = 5652.5; P = 0.0007) or Australian specialists (Mann-Whitney U test = 5652.5; P = 0.0007). This effect also held when answers for full-time staff only were examined.  

Knowledge of organisational goals and influence on management

 New Zealand specialists were significantly less aware of their health care organisation's goals than specialists in the United Kingdom and Australia, and New Zealand specialists had significantly less congruence between their personal goals and those of the organisation (Box 2). Specialists in the three countries were equally keen to influence management, but Australian participants felt their advice was less likely to be followed.  

Perceptions of changes in resources and availability of services since 1990

 New Zealand specialists felt that waiting time for non-urgent patients was longer than in 1990 compared with their United Kingdom colleagues (Box 3). Beds were perceived to be relatively less available than in 1990 in all three countries, with availability much worse in Australia and the United Kingdom. There was no difference in specialists' perception of equipment condition across countries; most considered this to be fair to moderate. New Zealand specialists felt that equipment replacement was much easier than before 1990 compared with their counterparts in Australia or the United Kingdom.  

Enthusiasm for work

 The Figure shows that 50.7% of specialists in the three countries (183 of the 361 who answered the question) reported decreased work enthusiasm over the past four years. The decrease in the United Kingdom was smaller than that in either Australia or New Zealand, but with this size sample no between-country differences were demonstrated (chi-squared = 4.6; df = 2; P = 0.10).  

Responses to open-ended questions

 The specialists' comments reflected a divergence between their perceptions of adequate clinical practice and the requirements imposed by the healthcare service reforms (see Box 4).  

Discussion

 We found that more than half of hospital specialists in all three countries had decreased enthusiasm for their work in the past four years, coinciding with a greater role of non-medical managers and more restrictions on resources in the secondary (hospital) care sector. The responses to the open-ended questions were consistent with this finding.

While all specialists acknowledged resource contraints, in the open-ended questions Australian and New Zealand specialists were more critical of their healthcare organisations than were the United Kingdom specialists. However, the consequent involvement of the United Kingdom specialists may result in a heavy workload:

"Sometimes the clinical work and admin work is overwhelming, but on good days it's great. Sometimes I worry if I can keep this level of activity up in the long term" [United Kingdom specialist].

The management structures in the employing organisations are such that specialists in the United Kingdom Trusts, particularly at Salford Royal, seem to be more involved in the organisation and management of their services than are Australian and New Zealand specialists. In this Trust, there were 26 clinical directorates, and more than 30% (26/79) of all specialists were clinical directors; although this position implies extensive involvement in management, the clinical director may not be the manager of the service.

A similar organisational structure did not exist in the Northern Sydney Area Health Service. At Capital Coast Health (New Zealand) only one of the three general managers was a medical specialist, and none of the departmental managers were clinicians. This may explain why there appears to be greater enthusiasm for work among the United Kingdom specialists and a greater acceptance of resource difficulties (i.e., although they perceived greater resource difficulties, they did not have less enthusiasm for work than their Australian and New Zealand counterparts). This involvement in management may also explain why United Kingdom specialists spend more time in committee work -- a level of involvement that is significant for their employer. On average, the United Kingdom specialists spent one hour more per week in management meetings than their Australian and New Zealand counterparts, and, given the standard working week of 40 hours, our study would suggest that a United Kingdom Trust employing 120 specialists could expect to receive an additional three full-time-equivalents of time commitment to management issues from those specialists compared with their Australian and New Zealand counterparts.

The results of our study show that for many hospital specialists health service reform has come at a "cost" -- a loss of enthusiasm for their work. Specialists' involvement in the management of their hospitals or services seems to be related to higher levels of enthusiasm, even when resource constraints may make it difficult for them to perform their duties properly. Our study suggests that the greater involvement of doctors in management is working to the advantage of the United Kingdom specialists and their employers. This could provide lessons for Australian and New Zealand healthcare systems that have values and structures in common with the organisations employing the Australian and New Zealand specialists in this study.  

Disclaimer of conflict of interest

 The authors declare no conflict of interest.  

References
  1. Hunter DJ. Doctors as managers: Poachers turned gamekeepers? Soc Sci Med 1992; 35: 557-566.
  2. Scrivens E. The management of clinicians in the National Health Service. Soc Policy Admin 1988; 22: 22-34.
  3. Ham C. Health care reform; learning from international experience. Milton Keynes: Open University Press, 1997.
  4. Ham C. Reforming the New Zealand health reforms. Big bang gives way to incrementalism as competition is abandoned [editorial]. BMJ 1997; 314: 1844.
  5. SPSS: Statistical package for the social sciences for Windows [computer program], version 6.1. Chicago, Ill: SPSS Inc, 1995.

(Received 28 Oct 1996, accepted 13 March 1997)  

Authors' details

University of Auckland, Auckland, New Zealand.
Rod J Perkins, BDS, MHA, Senior Lecturer in Health Management;
Keith J Petrie, MA, PhD, Associate Professor in Health Psychology;
Patrick G Alley, MB ChB, FRACS, Associate Professor, Department of Surgery.

Royal Salford NHS Trust, Salford, United Kingdom.
Peter C Barnes, MB ChB, FRCP, Physician and Clinical Director.

Royal North Shore Hospital, Sydney, New South Wales, Australia.
Malcolm M Fisher, MD, FFICANZCA, Clinical Professor, University of Sydney.

Wellington Hospital, Wellington, New Zealand.
Peter J Hatfield, MB ChB, FRACP, Renal Physician.

Reprints: Dr R J Perkins, Senior Lecturer in Health Management, University of Auckland, Private Bag 92019, Auckland, New Zealand.
E-mail: r.perkins@auckland.ac.nz


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