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Although information on variations in healthcare utilisation is increasingly available, its constructive use to improve health systems is often hindered by the lack of a clear standard to evaluate what is “good“ and “poor“ performance. This thesis investigates how regulators and managers of the system might address this lack of a standard. The thesis distinguishes between the purpose (to manage ambiguity in the absence of a standard or to determine a meaningful standard) and the approach used to achieve either purpose (socio-political or technical-evidential). The resulting four types of strategies are examined by drawing on concepts and methods from public health and epidemiology, health economics, operations research and public administration and empirical evidence from England and Scotland. To manage ambiguity in the absence of a standard using a socio-political approach, the thesis finds that one must overcome a series of barriers including awareness, acceptance, perceived applicability and capacity of potential users. Clinical and managerial leadership appear to be enabling factors for the use of information on variations for strategic problem framing and stakeholder engagement. To manage ambiguity in the absence of a standard using a technical-evidential approach, the use of ranking intervals and dominance relations obtained from ratio-based efficiency analysis can help to avoid the forced assignment of a single, potentially controversial ranking to each organisation under scrutiny. To determine a standard using a technical-evidential approach, estimating capacity to benefit in populations provides a theoretically sound and feasible benchmark to assess the appropriateness of service utilisation against population needs. However, uncertainty about criteria of capacity to benefit and lack of epidemiological data remain practical challenges. To determine a standard using a socio-political approach, an experimentalist governance logic focused on learning and dialogue between central government and local organisations can complement a hierarchist logic focused on accountability when both the ideal ends and the means for attainment are ambiguous. As a whole, the thesis reinforces the insight that both improved technical tools and social and political processes are required to make information on variations useful to decision-makers. |
