Managing the risk of infectious disease: The context of organisational accountability

The work reported in this article is part of a larger study funded by the UK Economic and Social Research Council (ESRC). The aim of the study was to determine how risks associated with infections and the control of infectious disease were managed in the NHS quasi-market. The specific objectives included an evaluation of the effectiveness of formal contracts, regulations and informal practices; the impact of professional and managerial systems on infection control; how financial risks of infection were distributed; and perceptions of risk held by contracting agents. This article reports on case studies in five sites. An understanding of formal and informal agency relationships and networks within each site was explored by interviews with key personnel who outlined how they perceived risk and their role in contracting. Insight into the budgeting and financial arrangements for controlling infection and dealing with outbreaks and how the financial risks were distributed was also sought. This article discusses the findings concerning the financial and budgetary arrangements for dealing with infection and its control. The theoretical framework adopted was that of institutional economics and it was within this framework that the effectiveness of contracts to control infectious disease was explored. Whilst contractual difficulties were anticipated, the extent to which the contractual process did not appear to be informed by those with most knowledge was unexpected. Transaction cost minimisation involves avoidance of costs to the contracting parties, which in this case, involves some knowledge of the risks of infection and the problems that might arise. Transaction costs cannot be minimised if the risks are unknown. Yet few officers with knowledge of and responsibility for infectious disease and its control had been party to negotiations of contracts. Moreover, the formal organisational networks established to deal with infectious disease were not used appropriately. In hospitals the cash limited budgets held by directorates had impeded the management of infectious disease by failing to take the public good aspects of infection control into account. It led to under-provision of services arising from the unwillingness of individual budget holders to accept financial responsibility for infection control procedures. The present arrangements have distanced those with expert knowledge from the process of drawing up contracts, left them with tenuous access to funds and