Ambiguities and complexities of obtaining value for money in the National Health Service : storytelling approach
This thesis examines a quest for Value for Money in the United Kingdom National Health Service, and how this quest has evolved over time. In the 1980s and 1990s the main issue was efficiency. After 1997 the focus shifted to effectiveness in achieving centrally determined targets. This thesis argues that in spite of considerable achievements, the Value for Money approach has "crowded out" CARE. Essentially, CARE involves sympathy, empathy and compassion. It has so many different manifestations in practice that a) it can only be shown through narratives, and b) this requires a more decentralised-bottom up approach than has been adopted by the Value for Money strategy. We represent Value for Money as a Grand Narrative in the sense of Lyotard (1979, 1984), and treat it as a representation of the archetypal Net Present Value model. The Grand Narrative is adapted to form the proposition of an Adapted Grand Narrative; that is, if implementers of the Value for Money strategy have different views of the categories than the designers of the strategy, then it will not be carried out as originally conceived. To capture the idea of CARE, a story approach, which we summarise as multi narratives, is adopted. The multi narratives derived from interviews are deconstructed using panel data, further stories and Socratic Dialogue, including ongoing academic dialogues. Using an openended interview approach, we find that disparity exists between the Value for Money strategy as perceived by the strategy designers in one part of the National Health Service hierarchy (or network) and those implementing the same strategy in another. The methodology adopted in the thesis becomes part of its recommendations. Asking people who implement strategies to tell individual stories that illustrate CARE will enhance the Value for Money strategy, and CARE can then become a route for enhancing the existing Value for Money strategy by placing value on the stories about the delivery of CARE. CARE, we will demonstrate, has multidimensional qualities, with some unique characteristics determined by situations and experiences. The framework of the approach emerges from a wide range of current and historic literatures related to Value for Money, ranging from the models of Irving Fisher to postmodern and post-structural perspectives of deconstruction, narratives, Socratic Dialogue, Differance, and the presence of the 'Other'. This multidisciplinary approach constitutes a significant contribution to the body of academic knowledge. In addition to this academic contribution, practical aspects result from the commissioning of parts of the study by the National Health Service.