outsourcing

#30 - Niels Uenk (Public Procurement Research Centre)

The challenges arising from procuring long term social services

Interview with Niels Uenk, part-time Researcher at the Public Procurement Research Centre a joint interdisciplinary research centre of the universities of Utrecht and Twente. Before joining academia Niels worked 5 years as international consultant in supply chain and logistics optimization. He specialises in public procurement of long term / social health care services.

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Transcript

Hello Niels, welcome to the programme.

Good morning Pedro, thank you for providing me the opportunity to talk about my research.

My pleasure, so Niels you have a mixed background because you’re working in academia but you’re still connected to practice, so can you give us a little bit of a flavour of what’s your actual background?

Yes, so after graduating my Masters in industrial engineering and management I worked five year in a private company called ORTEC like you mentioned in supply chain and logistics optimisation, and after five years I was ready for a new experience and I joined the Public Procurement Research Centre which has quite a unique position for me. Half of the time I get to work on my PhD research and the other half of the time I do paid work, so research and advisory work for other institutions, and basically to finance my PhD and that allows me to do my scientific research. Most of the other work I do is actually in the same area, so focusing on the procurement of social care services.

And have you been doing that for long?

I’ve been doing that since, well late 2013, starting my research around early 2014 actually.

Moving onto the actual research that you’re doing, can you provide us with a little bit more detail what are you actually doing your work on?

Yeah, and I’ll pay a bit attention to the context in the Netherlands as well, so my research focuses on the procurement of social care services, and in healthcare procurement we distinguish between two types: you have procurement for healthcare which actually boils down to buying anything from rubber gloves to equipment that is necessary in the process of providing healthcare, for example a buyer in a hospital, that is on the one hand, and on the other hand we identify procurement of healthcare, so actually buying the healthcare services often from healthcare insurer point of view, or from a public body’s point of view, buying or commissioning healthcare services. I strictly focus on the last part, and it’s a very relevant topic, I focus on the long-term care services, for example home care and a lot of care services that are not medical in nature, so it’s not fixing broken bones, or doing surgery, but it’s rather the type of care services that allow people with a disability or people that come of age to keep living on their own, to participate in our society, so it’s for example mental therapy for people with anxiety disorders, or also sometimes pretty straightforward assisting elderly with doing their tasks around the house, cleaning their house, and in doing so it prevents those people from having to move to an institutional home for the elderly. Especially in developed nations, the expenditure on these kind of services is rapidly growing and it’s one of the main concerns and challenges in healthcare for a lot of developed nations as well that the expenses and the expenditure is quickly growing because of for example the greying society. So in the Netherlands for example we spend about 15 billion euros a year on these kind of services, both for adults and for youth and it’s actually growing at a rate of 5% or 6% a year, much faster than our economy is growing, so that provides a challenge.A lot of other countries, the UK, I think the most countries in the OECD face similar challenges.

That is true and it’s certainly the case here in UK.

Yeah, in my research context what is very interesting is that in 2015 in order to do something against these rising costs and also to improve the quality, in the Netherlands we underwent a massive system reform where these services were previously centrally coordinated and centrally arranged (and procured), responsibilities switched, moved to local governments, so the municipalities, we have about 400 in the Netherlands, from 2015 became responsible for arranging and thereby also procuring these social care services. It was one of the biggest system reforms in the last I think 60 or 70 years, the budget involved like I mentioned is about 15 billion euros and the municipalities got a lot of freedom to actually manage these services to their best insight. That creates a very interesting situation where a lot of municipalities are choosing different ways of commissioning these services, choosing different ways of paying for these services, they are designing their own system of how people should apply for these services and a lot of different approaches are visible right now which for me as a researcher is obviously a very interesting position because I actually get to, on the one hand investigate how municipalities are approaching the procurement and the commissioning of these services, and then see if the difference between those approaches actually results in better or worse care for the citizens. So that is basically the main topic of my research, how are there municipalities contracting this care and does a different approach need to improve quality, reduce costs, etc.

It’s interesting because my impression here in the UK is that long-term care services are procured by local authorities separately from healthcare, so and one of the discussions that I’ve seen over the years popping up time and time again is actually merging long-term care or social care with healthcare procurement, because at least in UK there’s the view that by keeping them separate each one of those two systems tries to shift patients to the other system so that they don’t have the cost.

Yeah.

So what’s the experience in the Netherlands if it’s possible to find any kind of information about it right now?

One of the reasons for decentralising long-term care to municipalities is in fact to try and bundle a lot of responsibility within this social care sector with the same organisation, so that the municipalities have a very wide responsibility right now for any kind of support, social support, social services that may be necessary within the situation of a client, so before for example the social care for youth was very fragmented in the Netherlands, where provinces had responsibility for one part, regional offices of healthcare insurance agencies were responsible for a different part, and the local government and the central government was responsible for a third part and all these different parts have now been combined and made the responsibility of the municipality. Indeed there is still a distinction between the private, the curative healthcare procurement, so the procurement of hospital care and basically any type of care that actually involves medical care, (and the social health care procurement, red.) there’s still a division, and there is still also debate on whether certain types of care will be decentralised in the future as well, in order to optimise and be able to manage as integrative care system as possible. But for now these types of social and home care, as they are quite different from the medical care you receive in the hospital, the municipality already have quite a lot of responsibilities as they have right now.

Moving onto the research that you have actually done so far within your PhD, as far as I know you’re doing it in a similar way to one of my previous guests, Suvi Taponen, you’re basically doing your PhD by publications, am I correct?

Yeah, that’s correct.

So what have you been doing so far and what have you concluded in terms of research?

One of the first things I started to do, I started right in the year 2014 when all the municipalities have had to contract these homecare services, and what I did was, well I wanted to find out to what extent these municipalities took different approaches with respect to procurement. They all came from the same situation: before 2015, the procurement was standardised for the entire country, the same products, the same tariff structure, the same procurement procedures were applied. The first thing I did when I started was to collect the procurement documents and tender procedures and any kind of information on how municipalities actually procured these services, for as many municipalities as possible. So I started making a database with all the tender documents, all the contracts I could find, and most of the municipalities actually published these services, or these contracts which in 2014, was not actually required from public procurement regulations because these services are actually back then part of appendix 2B-services (EU regulations on public procurement, red.) that were exempt from most of the public procurement regulations. The municipalities, most of them, published their contracts anyway and I made a database of that and the database I have has about 95% coverage of all these tender documents of all the municipalities, so there are approximately 400 municipalities, I have the tender documents about 385.

That’s a big dataset.

That’s quite a big dataset, I have to say thank god for me most of the municipalities actually also collaborated, so it actually boiled down to 90 different tenders, still it’s quite a big dataset because most tenders, well if you have seen public tenders before you know they can contain quite a lot of different documents and quite a lot of extensive documents.

The next thing I did was, well to actually build the database with analysis of these tender documents, of well about 20 different factors ranging from aspects of the procurement process: did the municipality collaborate with the procurements, how big was the collaboration in size, how many different municipalities joined, what kind of procedure did they follow and then there was a lot of negotiation going on and a lot of dialogue in those procedures, was the procedure open for any kind of care supplier or did the municipality invite a selection. I also analysed the content of the contracts: what kind of products did they procure, did they simply copy paste the product lists that was used before 2015 or did they create new products, what kind of reimbursement method did they apply. So I analysed all those tenders based on all these factors, also what kind of tariffs did they pay and I created one quite big database based on the procurement approach, each individual municipality or collaboration took, and it is actuallynow my starting point to also write scientific papers based on this dataset. So I have the first paper out, it was just yesterday accepted at the IPSERA conference, so I’m very pleased with that as a competitive paper, where I will present the results. In the paper I first do an analysis on what kind of aspects are relevant to study based on literature (on service triads, red.) and I then present the approaches of the Dutch municipalities, how they went about with respect to the relevant aspects.

You’re still working in practice so you’re just doing the research part-time and working at the Public Procurement Research Centre in a part-time basis, so from your perspective what are the challenges of managing this joint or dual track kind of life, managing research and practice side-by-side?

Let me highlight first the good things about it and then the challenges, obviously or what I really like about the joint work is I get to apply the knowledge that I find from the research and I get to directly put that in practice, or make use of that in practice, so more and more municipalities are inviting me to come and talk about my research, they want to know how do other municipalities tackle certain problems, they want to have an overview of different approaches that may be possible and well because I analysed that for my research I have a nice overview and I can directly put that into practice. Also, sometimes municipalities or also care providers, well they have like quite practical problems or issues they deal with, and it also keeps my research relevant to practice, because I’m not just doing some very theoretical research, because I know what kind of issues the practitioners face, I can also know what kind of relevant research questions I should focus on to actually be able to do research that is directly relevant not only for the scientific community and for our knowledge, but also for practice. Now that’s what I very much like about my position, one of the main challenges and I think every part-time researcher will provide the same answer is that for my work related activities there’s always something, there’s always a deadline and there’s always something waiting for an answer. And for my PhD that may also be the case, but the deadline is always a bit more soft, or if I don’t do the work this week well nobody is going to shout on the phone to me that I haven’t... so one of the big challenges is actually to on a weekly basis make sure that I also spend enough time on research, and yeah, I don’t have a very strict planning that the university keeps me to from when I should finish this article and when I should finish that article or that paper, but that actually increases the risk of not doing enough research and letting your agenda be dominated by the work related activities.

It’s interesting that you’re highlighting that because I felt exactly the same thing when I was doing my Masters, maybe 12 13 years ago, and I was working as a lawyer at the time and I just could not pull it off, exactly because what you’ve said, because if you have work related commitments they tend to have very tight turnaround timescales attached to them and certainly as a lawyer that was the case, there’s always stuff that needed to be done in that day, so you keep on pushing out for later and later those deadlines that are not as strict, and it’s almost like an adult version of the marshmallow test that it’s done with kids, so that if we delay gratification and actually work on those softer deadlines we’re going to be better off on the long-term instead of just fighting fires every day. But I could not pull it off so I ended up actually once my decision was made to do a PhD in actually moving full-time and I never considered even the possibility of doing it part-time as you’re doing so I have a huge respect for the researchers that are able to do those two different jobs and roles at exactly the same time because I find that incredibly incredibly challenging. Now one of the things that I really liked when I was a PhD student is that my supervisor was very, I wouldn’t say strict, but very assertive with deadlines, and that is something that over the years once I became PhD supervisor myself as well I found to appreciate more and more, which is it’s important to give PhD candidates a certain structure and a certain timetable that builds on them a certain rota or a certain way of doing work so that they can expect to submit a piece of work, be it a paper, be it a chapter, half a chapter, 5,000 words, whatever, with the certain cadance, i.e., a certain number of words, a certain number of pages every four weeks or every six weeks because that creates the habit of producing work constantly. And that worked really well for me as a student and it works well for most of my PhD students as well, so sometimes I think, and I have these discussions with colleagues, that we sometimes leave PhD students to their own devices and say, okay, they’re doing a PhD so they’re supposed to be autonomous, it’s up for them to manage their own time. And that is sometimes very hard and especially I would say it’s doubly hard for people like yourself when you have other competing interests, in this case actually a part-time job elsewhere.

Yeah, it is for me one of the main challenges, and having worked in a consultancy firm five years before starting my PhD I think actually helps me to have the, to make sure…

The discipline?

Yeah, the discipline, that’s what I was going, to have the discipline to make these deadlines for myself, although yeah like I just mentioned it remains being challenging, I don’t have a supervisor that’s strict with me and if I would have it probably would help, would help as well.

Okay, I’ll send him an email saying that!

Yeah, but I try to do this, I’m collaborating also on a few papers from time-to-time with others and I try to make deadlines on myself if I have agreed to work on something and to have it finished with a colleague it helps me because I hate to be late or to not manage that deadline. So I I visit a lot of writing workshops through my contacts at IPSERA, I get invited to writing workshops and I tend to use those workshops and those days as deadlines to just make sure that I have something done, have a new version or concept version of a working paper done, and working from conference to workshop to, well those are actually the deadlines that make sure that I, well writing enough. But to be honest right now for me it becomes much more important than in the first year because in the first year I did the collection of that data and it was both for the PhD but also for some external projects it was relevant, so up till now I’ve been able to combine a lot of the research activities with my activities in practice, but the writing of scientific journal articles, well that’s purely for my PhD, so I’m much more in the phase where I have to produce those papers where a lot of the data is already collected, so it actually becomes much more important in this stage of my research to keep those deadlines and to keep in what we mentioned, a certain cadance of producing scientific articles for book chapters, compared to 2015 and early 2016.

What do you see yourself doing after you finish your Ph.D, do you want to stay connected with academia, do you want to go back full-time to practice?

To be honest I don’t know yet, I very much like the position that we are in to be able to do really scientific research from university point of view producing to sometimes discuss about a research and the methods used with colleagues and to be able to, well improve the quality of research compared to some of the reports written by other firms, sometimes consultancy firms that sometimes just need to quickly produce something with maybe a more commercial motivation, so I really like the scientific base where we come from. But yeah of course if I want to stay in science and in academia writing and producing there’s much more emphasis on that (getting published) after the PhD maybe, so to be honest I'm not sure yet.

Very well, I think it’s a great way to finish the interview. Niels, thank you very much for coming.

Yeah, it was a pleasure, I feel like I haven’t discussed a lot in detail of some of the stuff I’m doing but maybe that’s also not for the greater audience, a bit less relevant, but I thank you for the opportunity and well I think it’s a very interesting way of sharing research with the world, so thank you and very interesting project you have.

 

#29 - Suvi Taponen (Aalto University School of Business)

Risk management in outsourcing of health services

Interview with Suvi Taponen MPA, a Doctoral Researcher at Aalto University School of Business, who also works as a Procurement Consultant. She will defend her thesis entitled ‘Improving the efficiency of public service delivery through outsourcing and management’ in the beginning of 2017, and she has worked previously at Hansel, the Finnish centralised purchasing body. The conversation is focused on the management of outsourced healthcare services, the core of her research.

Transcript

Hello Suvi. Welcome to the programme.

Oh hello Pedro. Thank you.

 

Thank you very much for accepting to be interviewed. I really like to get as many interviewees as possible from various backgrounds, so could you describe a little bit what is your background please?

Oh yeah, sure. And thank you for asking me to participate. It’s really a great honour. I’m happy to speak with you. My educational background is in public administration so while I was doing my Masters I studied public management and also public law, and in my Masters thesis I got involved with public procurement. I guess that’s the initial reason why I ended up here where I am at the moment. And after graduating as Pedro you mentioned, I was employed by the Finnish central purchasing body for the government and I worked with Hansel for four years. In the beginning I was an assistant responsible for contract management and after one year I transferred to a sourcing consultant’s role which meant that I was then, I wasn’t working with framework agreements that much anymore, I was consulting individual procurement that the Finnish ministries and other organisations such as the universities that are funded by the government were doing. At the time I mostly worked with IT purchasing but also quite a lot with services. And after two or three years of practising I kind of felt like well I know there’s quite a lot of inefficiencies, the way that the government organisations operated, not only within their procurement functions but also mainly with how they were purchasing and why they ended up purchasing and at what stage of their planning of the year or planning of their service delivery. And that’s how I ended up considering taking up a PhD and well that’s almost an accident. I just dropped a casual email Aalto University School of Business and then I was connected with the right person who is now my supervisor. At that moment I wasn’t to be honest that serious about it, I was, and then, well then actually Professor Katri Kauppi asked me to come over and then we ended up talking and we definitely shared the same ideas and also shared the same ideas about how the public sector should be developed, especially in the Finnish context.

So I started out my PhD as a hobby, as crazy as it sounds. I was, in 2014 I was still working as a full-time consultant for that centralised purchasing body and then I was doing my research on the weekends. I already had the idea of starting off with looking at the make-or-buy decisions but I was really interested in the reasons of why public sector is outsourcing its services and what are the reasons behind it and is it always sensible to do that?

So that was the main motivation for my PhD because in Finland maybe you wouldn’t think that as we have been one of these traditional welfare states but outsourcing public services has been a really popular trend for maybe almost twenty years now. So it was really interesting in that phenomenon that what are the reasons and it felt like, and to be honest it still feels like that the outsourcing decisions are too much based on ideology and political agendas. So that was the main motivation for my whole PhD, directly into that issue, the outsourcing of services in the public sector context.

 

Did you think at the time it was important to answer that question or look into that question?

Oh yes. Because there were quite a few, of course the papers love to cover, especially the cases when outsourcing goes wrong, and it seemed like there weren’t too many facts presented in relation to analysing the results of outsourcing. So I had this doubt in my mind that maybe outsourcing, yeah,I think I kind of changed my mind, but in the beginning I thought that outsourcing maybe should be used more, that maybe public services should be outsourced more, they were outsourced at the time but then I realised that I need to look into the facts and provide some proof that would support a statement.

 

That is a very good point because it’s part of the process of doing a PhD is that we always carry with us our preconceptions and say “oh we think we’re going to find x” or this is what you’re going to be arguing at the end. And based on my own experience and also my experience of supervising PhD students, that often is not the case in reality, is that you actually changed your perceptions as you do the PhD, which shows that you’re actually doing a PhD and you’re just not trying to find only the sources that confirm your pre-existing bias?

Mm. Yeah, you’re definitely right. It’s you always have these ideas that you think that you’re going to be able to prove. But I think, yeah, I agree with you definitely that it’s extremely important and an essential part of the PhD process to accept that facts aren’t like you hopefully thought they would be and accept that, you know.

 

So you decided to do that research into outsourcing. What methods did you deploy in the PhD?

Mm, yeah. My PhD it’s an article-based PhD so it means that actually within one PhD thesis I have done four individual pieces of research. So they’re all individual research projects with different kind of methods and they kind of go through the outsourcing phase. So I started off with make-or-buy decisions as I mentioned and that’s a qualitative case study with a comparative perspective. So what I did, I had eight cases in total, four of them were from the public sector side and four of them were from the private sector, and well looking back now being a bit critical I noticed that maybe I should have included a bit more organisations but the small number is explained by the fact that as I wanted to compare the make-or-buy decision processes, like what triggered the process and what kind of criteria was used, I recognised that I need to have service deliveries that are actually identical in both sectors and those kind of services weren’t that easy to identify. And then in the end I went with occupational healthcare, translation services, leasing services, so that’s funding and also taking care of all the IT equipment and then customer services. So I was only able to get those kind of cases in Finland and four of those services.

So then what I did, I collected interview data from each case organisation and also used some written material I was able to get from some of the organisations which for instance described their decision making processes, if they had a model for that and so on. That was the first paper.

 

So that was the first paper that you did, so you did a qualitative case study…

Yeah

 

and took a comparative perspective? Well I mean as you’ve highlighted it’s important to make sure that you can actually compare and be sure that you’re comparing apples to apples and not apples to oranges because otherwise you’re screwing up the data. So that was the first one you did. What did you do after this qualitative case study?

Yeah. Well actually I used that same data for the second paper or second article of my PhD as well. So at the same time when I was collecting this data I also asked the interviewers in the organisations about the transition phase because in all of these cases, eight cases, the result was to outsource all of the service delivery or outsource a part of that. So then also in the interviews I discussed with them about management of the transition phase and also contract management. So then the second article of my PhD which is actually also my first publication that is about to come up, it’s already available online which is really exciting, so yeah. So this second article was also a comparative study between the public and private sector but the perspective of the comparison was a bit different, as in the first paper the comparison is about identifying best practices from both sectors and, well we’ve been resubmitting the paper quite a few times, in some versions we are actually offering the recommendations for both public and private organisations but in the second paper it’s all about public service management.

So then in that paper the perspective is to use the private sector’s data to identify best practices that public sector organisations could absorb and implement. And I think looking back now that was a bit more, or is a bit more successful perspective as I recognise that in many of these ideas that I’m looking into, especially the make-or-buy decision, it’s really largely and already covered in the private sector’s specific research context. So the article is really, there’s practically nothing new if you put that in the private sector context but then if you especially try to make contribution to the public sector side, then it might provide more novel contributions.

 

On that note, I mean one of the things I find important to always take into account when you’re looking at private sector practice and how it could be transferred into public sector is how do you account and how do you control for the differences in terms of decision making and especially in terms of incentives between the two kind of organisations?

Yeah. Especially in the public service management paper we recognise the fact that it’s an issue that private sector organisations that are able to incentivise, provide incentive, monetary incentive, so promise more salary, higher salary if a person delivers better outcomes, but at least in Finland the contracts that the public sector employees have and what the unions have negotiated on behalf of the employees and also the employers is that they are not able to offer a similar kind of contract to their employees and incentivise achieving their outcomes for the service delivery.. And actually in some cases this has led to outsourcing services to private sector so the flexibility that they have in their contracts with their employees, so definitely you’re onto something when you bring that up.

 

Okay. So that was the second paper. Can you talk briefly about the next two please?

Yeah, sure. So then moving onto the third paper and it’s actually, yeah, that was a good thing that you brought up the specifics of the public sector organisations and how can you, how you cannot actually compare them entirely, the private sector, this was really highlighted in the third paper of my thesis which is about the risks of outsourcing a health service function.

So just to provide a brief background about that, in Finland it has been a huge trend to outsource. Some of the municipalities that at the moment still are responsible for delivering healthcare, they have actually outsourced all the services that they are responsible for providing to private organisations. So there has been a big trend of this total outsourcing in relation to healthcare. So my third paper I have, it’s a single case study from a medium sized city in Finland which has, the city has twelve outpatient clinics in which it provides primary healthcare and the city had already outsourced two of these outpatient clinics. And then actually from a private health service provider I got the information that now they are thinking about outsourcing more of these outpatient clinics.

In the third paper I combined, well it’s not a, I shouldn’t call it a survey but what I did I interviewed their whole project team that was preparing the invitation to tender and the suggestion from the City Council how the outsourcing should go about. At first I sent them a questionnaire and they all listed what kind of risks they see involved in this outsourcing idea that they were planning on and they gave values to these risks, two kind of values on the Likert scale, 1 to 5, how likely is the risk to realise and how bad are the outcomes, or what’s the impact of the outcomes if the risk realised? And after the interviewees had filled these blanks then I did interviews with all of them. And in the interviews we discussed the risks that they have identified and then we also talked about the state of risk management at the moment within the city and they also shared some experiences that they had from the previous outsourced outpatient clinics that they had. And actually my idea was to do a bit of a longitudinal study but what happened I was able to publish that paper in relation to the IPPC7 conference last summer. So it ended up being a bit, the scope wasn’t as wide as I figured in the beginning but it’s actually quite nice that then I had all the, as you have a limited amount of characters for the publications I was able to actually focus on what are the risks in the outsourcing consideration phase and how the contracting authority should mitigate these risks during the quantitative tendering procedure.

And now as my thesis is under pre-examination I’m actually continuing this research. So I went back a year after the interviews with the city and its employees and asked how the risks had developed within the year and what was the result of the tendering process, and now I’m actually, it is pretty exciting just Tuesday this week I also did interviews with the selected supplier so they are now also sharing with me the perspective on risks that they had while they were preparing the tender and now, and when the service is actually already running so from the transition phase.

 

And is it working well?

Yes. The results are good but actually doing the tendering process they, we identified that there’s a political risk involved as I mentioned that the final outsourcing decision is made by the City Council in Finland in the local government level. So what it means that the civil servants they’re preparing the suggestion and what they suggested was that they should outsource two outpatient clinics but what the City Council ended up deciding is that they only outsource one. And now looking back the civil servants still were, there were a bit heated discussions when they looked back to the decision because they really thought that the politicians were, there is an election coming up next year, yeah, so they were really frustrated with the fact that they felt like the election had more impact on the decision that the facts that they provided so…

 

That’s a great example of the differences between dealing with private sector and public sector?

Yes, definitely. So they’re really happy with the one now, the outcome of the outsourcing in terms of the one outpatient clinic, but the problems that were driving outsourcing and triggered the consideration they still exist within the outpatient clinics because obviously the politicians didn’t actually have the means to improve the state of the service delivery internally.

 

Okay. And what about the final publication, the final article?

Oh yeah, the final article I actually did with, that wasn’t, all of these I did while I was working at the Aalto University School of Business but last spring I spent at King’s College Policy Institute in London. So my final article is in the UK context and in the context of National Health Services, so NHS, and that’s about looking at the purchaser provider relations after outsourcing has been done, so it’s looking at contract management. And it’s, we had the, yeah, I did that with Saba Hinrichs-Krapels from at King’s College and what we looked at was how to cooperatively develop care, the outcomes of care, then you have outsource delivery, and that was also a qualitative case study. We had, in England there are these Clinical Commissioning Groups that are responsible for purchasing care and I think there are more than two hundred of those, so from the two hundred we were able to get twelve organisations that gave us interviews and in addition to interviewing the representatives of the Clinical Commissioning Groups we also got a few interviews of these strategic organisations that work nationally to improve care.

And the process of case selection in this, my final paper was actually quite interesting. It wasn’t as easy as it was before, as in actually not too many people are working with public sector in Finland and of course there is quite a lot of research going on but not that much research as in the UK context and especially the NHS, I think they’re a bit sick with researchers and all these organisations collecting data to improve their operations to be honest. So as in Finland contacting case organisations basically were like just giving them a call, introducing myself and after that they were happy to welcome me to give the interviews, it wasn’t as straightforward in the UK context. So we did quite a few rounds of emails and we struggled a bit getting case organisations but then we decided that okay, maybe we should consider only to one service, use one service as an example and then maybe we are better able to identify potential case organisations more efficiently and then also we realised that it will make identifying, achieving the goals of our research of identifying the means for cooperative development easier.

In the beginning I was only able to get two interviews and based on those we identified that cancer care is a really topical thing in the UK, topical in the sense that there has been a national programme of improving the care for cancer, there are huge variations in the quality of care…

 

That is true, yes.

Yeah. So that drives improvement of the care. So a lot of the Clinical Commissioning Groups were focusing on cancer care at the moment. And then I mentioned that there are these strategic networks that focus on three care areas, one of which is cancer care, so by contacting those organisations we were able to get a list of potential interviews, interviewees and organisations and actually I think one of the people working in these strategic networks actually requested them to participate in the research for us and that really helped. And then in the end I think I did maybe sixteen interviews which was enough to get, to be able to draw conclusions. But definitely was a tricky process which demanded a lot of persistence and patience to get all the interviews.

 

And in terms of findings, what can you tell us in terms of your main findings from all your research then over the last few years?

Yeah. It was definitely a big challenge when I was finalising my PhD to draw all of this together. I thought it would be a bit easier. But I think the main finding if I start from the beginning is that in terms of outsourcing triggers definitely private organisations they’re proactive. They kind of analysis the service delivery all the time continuously, well not every day of course but at least every quarter or twice a year. But what public sector organisations they typically outsourced when they have problems that have already realised in their service delivery, so they don’t really do it proactively. Of course there are some exceptions but the typical cases that the service availability is so poor or the service quality is so poor that they absolutely need to do something.

 

Why is that? Why is private sector much more proactive whereas public sector tends to be more reactive? Did you find anything, any justifications or explanations for that fact?

I think, well now speaking in the Finnish context, I think in Finland we actually, our public sector has been quite wealthy for quite a few years so they haven’t been until now, the scarcity of public funds has been a reality for quite a few years but before there was quite a lot of tax money to use for the operations and for the service delivery. So there wasn’t this demand of organising operations really cost efficienciently or that effectively in terms of quality. But then I think within the last ten years there has been less and less money to use for the service delivery and that has created a demand to deliver care with better impact with lower costs, as in if you think about private organisations they wouldn’t exist if they are not financially sustainable and cost efficient so…

 

So that brings us back to the question about incentives then, how the incentives play differently between public sector and private sector leading to different outcomes and strategies?

Yeah. So basically from the first paper we established that considering outsourcing makes sense if the service demand varies a lot. So then of course it’s hard to figure out how many employees you should employ in-house so it’s easier to outsource a service, but the demand varies so out to a supplier who provides that service to several clients. So that was one of the main findings that in that situation you should consider outsourcing. And then we also mapped the process of how you should go about the consideration.

 

Okay. So I think we’re getting close to the end of our interview. What do you think you’re going to be doing next? What are your next steps in terms of research that you’d like to turn your attention to?

Oh yeah. Well in the last two articles of my PhD I focused on healthcare, so I think that’s the main focus area. And then one of the reasons is also that Finland is currently in the political process of reforming the delivery of healthcare, so based on the piece of research I did in the UK I also identified the organisational structure and analysed that and contributed to the political process a bit by providing a report. So I think that’s something I’m going to continue working with.

I’m also now employed as a Consultant so I’m already returning to practice but I am hoping to continue the line of research with health services that I’m doing. So as I mentioned I have some more data on this risk paper so I’m going to continue developing models on public sector risk management, especially in the context of health service outsourcing. And then, well let’s see how, I’m not quite sure after a few years how I’m able to combine practice and research but hopefully well because I enjoy them both, so yeah. I’m a firm believer that a hybrid career is possible but let’s see.

 

Yeah. I find it interesting because one of the things I miss being full-time in academia is actually working in practical problems and solving practical problems, so it’s no surprise that when I actually do research most of my research tends to have a practical focus or a practical emphasis because it’s just me being pulled back to my origins as a lawyer and not someone that has made all his career in academia. So Suvi, thank you very much for taking the time to be with us today.

Thank you.