Skip to Content

Home » Research Projects » Regulation, ‘Donated Labour’ and the NHS Reforms

Have NHS regulatory reforms undermined altruism in the health workforce?

Public sector productivity and service quality is often held to be dependent, at least in part, on non-financial incentives- public sector motivations (PSM) – the beliefs values and attitudes that go beyond self-interest to include concerns for the needs of others and the greater common good. It is also often claimed that those reforms that treat those working in the public services as ‘knaves’ rather than ‘knights’ – by low-trust controls such as audits, assessments and targets – risk unintentionally undermining such altruistic values.

The English National Health Service over the forty years from 1966 to 2006 offers a particularly good opportunity to put these propositions to the test. The project looked at such questions as: What has happened to labour productivity over this period of management and regulatory reform? Do clinicians work for longer than they are contracted (`donate labour’) as much now as formerly? Do changes in clinicians’ attitudes and behaviour support or contradict the idea that if ‘knights’ are treated as ‘knaves’ they will indeed turn into ‘knaves’?

What the research means for policy-makers and the wider community?

Research Methods

The researchers used face-to-face interviews to obtain information about working patterns over the period 1966 to 2006 for 3 cohorts of doctors and nurses at the University College London Hospital NHS Trust – those that graduated before 1970, between 1970 and 1989, and after 1990 – in order to assess the strength of intrinsic motivations and how these might have changed. This information was combined with psychometric profiling data obtained from the same sample of doctors and nurses to test how personality traits affect working patterns. This information was mapped against the specific regulatory innovations that occurred at the UCLH Foundation Trust – and the concurrent incentives and sanctions these generated – over the same period to explore the extent to which changes in working patterns corresponded with the introduction of different regulatory and managerial reforms.

In addition, data was obtained for 1989-2005 from the Hospital Episode Statistics database for the main specialities at UCLH, along with comparable data for other London Teaching Hospitals and for all hospitals in England. This allowed an analysis of the effects of the reforms on activity and clinical productivity. These various analyses opened-up a multitude of avenues for further investigation into the complex interactions between motivations, regulatory incentives and sanctions, personal characteristics and productivity.

Project Outputs and Related WebpagesThis project has a dedicated webpage on the Oxford Policy Institute website.

July 2009 (pdf) : NHS Reforms at University College London Hospital by Roger Hay, Jerrett Myers & Tim Ensor.

May 2009 (pdf) : Management Reforms and performance in a London Teaching Hospital by Tim Ensor, Anne Kilby, Jerrett Myers  & Roger Hay.

 June 2008 (pdf):  Public Service Motivation and Performance Incentives: a literature review by Jerrett Myers

March 2008 (pdf) : The Economics of ‘Public Sector Motivation- a Literature Review by Martin Karlsson.

Research Team

Tim Ensor

Dr. Tim Ensor is Senior Research Fellow (Clinical), University of Aberdeen School of Medicine, Department of Public Health and Research Fellow at the Oxford Policy Institute. At the University of Aberdeen he leads an international comparative research programme. Prior to that, he was the leader of the International Programme, Centre for Health Economics at the University of York. He has worked on research and consulting projects in East Asia, Eastern and Central Europe and Sub-Saharan Africa and published extensively. His current interests are in health workforce incentives, international health labour markets and health sector regulation. He has been a major contributor to the development of Oxford Policy Institute’s health portfolio.


Jerrett Myers

Jerrett Myers is a Senior Researcher at the Institute for Government. He was previously the Research Coordinator at the Oxford Policy Institute. He holds an MSc in Public Policy and Administration from the London School of Economics and Political Science. His thesis investigated the incentives researchers have to transfer knowledge to public sector managers. He was formerly a civil servant in the Science Policy and Planning Directorate of Agriculture and Agri-Foods in Ottawa. He studied Public Affairs and Policy Management at Carleton University where he gained a number of awards and was a teaching assistant in the Department of Law.

Roger Hay

Roger Hay was Director of the OPI. His recent research activities included a study in Cambodia on health sector pay and administrative reform designed on the basis of a clinical incentives analysis. Earlier he worked on health sector reforms in Georgia, Russia, Vietnam, the Caribbean and all of the English-speaking Sub-Saharan African countries.

Anne Kilby

Anne Kilby recently retired from UCLH as a paediatrics consultant and was formerly Clinical Director for Paediatrics.

Paula Palmer

Paula Palmer is an industrial psychologist with extensive human resource management experience in the NHS.