Sense of place, organizational context and the strategic management of publicly funded hospitals.

An era of managerialism in health care delivery systems is now well ensconced throughout the nations of the OECD. This development has occurred, in large part, as a response to funding pressures in institutionally based health care delivery imposed by principal third party insurers. In the case of publicly funded hospitals, the more traditional concerns for stewardship and appeasement of professional groups is being replaced by a greater emphasis on cost consciousness and corporate-style leadership as these organizations seek to reposition themselves in new funding and regulatory environments. While institutional theory and strategic management perspectives help illuminate these issues, this paper argues that a place-based perspective is also needed to understand the changes currently underway in health care delivery and publicly funded human services more generally. This is illustrated with reference to developments in the strategic management of public hospitals in the province of Ontario. Evidence from a survey of senior administrators of public hospitals, distributed at the height of these policy reform initiatives, is examined to shed light on local level management responses to changing policy and fiscal pressures. The data suggest that the latest policy directions in the province of Ontario will 'encourage' hospital executives in particular community settings to steer their organizations in very unfamiliar directions. The findings suggest a need for greater attention to context and setting in health services research and policy.

Access and utilization: a continuum of health service environments.

Birch and Abelson [1] argue that non-income based barriers might explain differences in utilization of health services within and between income groups. Databases which contain utilization data rarely allow for the modelling of geographic variation. In the Ontario Health Survey (OHS), individual observations are georeferenced at the Public Health Unit (PHU) scale, but PHUs cannot easily be used because of the large coefficients of variation. To overcome this problem, a cluster analysis is performed to create a service environment variable, which reflects differences in service availability, population size and rurality. Utilization of health services is then modelled as a logistic regression equation where the independent variables are age, sex, service environment and income to test the Birch and Abelson argument. This argument is then extended by controlling for age, health and income status. Based on the modelling results, the importance of geography to access and utilization is assessed.