Quacks and Clerks: Historical and Contemporary Perspectives on the Structure and Function of the British Medical Civil Service

The British government's requirement for expert medical advice from the 1850s led to the development of a medical civil service, which reached its peak in size and authority in the 1970s. By this time the Chief Medical Officer (CMO) had direct management of a staff of over 170 medically qualified civil servants, who provided expertise on the development and implementation of new medical treatments as well as on broader health protection and promotion issues. The successive Whitehall efficiency reviews from 1979 onwards culminated in 1994 in the merger of the parallel medical and civil service reporting hierarchies in the Department of Health, effectively reducing the CMO's ability to call upon the support of medical civil servants, at a time of increasing new health threats such as AIDS and MRSA. This article uses government reports to chart the rise and fall of the British medical civil service. It discusses how, in the last ten years, the British government has become more imaginative in its use of temporary specialist medical advisers (tsars) brought in from the NHS, in relaxing the formal civil service hierarchies, and quietly abandoning the statutory Standing Medical Advisory Committee (SMAC). This article suggests that when the government has failed to give adequate support to its CMOs, the medical civil service has suffered from poor morale, experienced recruitment difficulties, and the ability to respond to health crises has been compromised. It highlights the chronic lack of historical awareness in the development of health policy in Britain.     

Job satisfaction in Cascadia: A comparison of British Columbia,Oregon, and Washington civil servants

Canada and the USA share a common cultural source in the British Empire, yet within shared democratic traditions, very different political structures, policy processes, and values have been identified. Canada is seen as having a more deferential culture more supportive of government while Americans have been argued to be more individualistic and cynical about the role of government in society. Using a political culture framework, this study examines the degree to which Canadian and U.S. civil servants perceive societal respect for their public sector jobs, and the impact of those perceptions on individual job satisfaction. It is argued that if civil servants feel more valued by society, they are more likely to have higher levels of public service motivation, which then contributes to higher levels of individual job satisfaction. This study employs surveys of Oregon, Washington and British Columbian civil servants conducted in 2011 and 2012 to investigate this relationship. Findings suggest that British Columbian civil servants feel more valued by society when compared to Oregon and Washington civil servants, and these perceptions of positive societal support are associated with higher levels of individual job satisfaction.     

Devolution and Patient Choice: Policy Rhetoric versus Experience in Practice

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK‐wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro‐level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.     

英国医疗卫生体系问题与医疗卫生政策改革研究

健康是人们福利的重要组成部分,因此医疗卫生政策和体系是社会政策的重要领域。该项研究从贫穷、低收入和健康之间的关联中评估人们对医疗保健的需要;指出英国存在全科医生、医院医生及公共卫生医生是医疗卫生服务提供的主体;英国在医疗卫生政策改革方面的内容包括:(1)对英国全民医疗体系(NHS)多渠道的财政支持,(2)提高服务质量的机构管理改革,(3)实施提高服务质量的安全、有效、病人中心、及时、效率、和平的原则;英国存在的强大政治集团及其利益影响着改革;政府需要在减少医疗服务中不平等和提供及时有效的服务方面努力。     

Minding the minister? Ministerial advisers in New Zealand government

Abstract

In recent years, political advisers have been in the spotlight in a number of Westminster nations. A surprising feature of the literature, however, is the relative lack of empirical attention paid to advisers themselves. Moreover, researchers have tended to focus on the accountability issues raised by the conduct of political staff at the expense of other significant matters, including advisers’ views of their influence on the policy process and on relations between ministers and public servants.

This article seeks to redress those gaps. Drawing on data from a survey of New Zealand's ministerial advisers, it describes the activities advisers engage in, and sets out advisers’ views on their contribution to the policy process, their bearing on relationships between ministers and officials, and the state of their own relations with public servants. It concludes that the ministerial adviser's role in the executive branch of New Zealand government is more varied and comprehensive than is frequently assumed.     

The Organization of Health Policy Functions in the German Federal Government

This article gives an account of the organizational history of the German federal ministry of health (and its predecessors) since the beginnings of public policy intervention in health care. In doing so it analyses the role of ministerial organization and examines the functional and political rationale underlying acts of reorganizing the tasks and resources of federal ministries. This analysis has two sides: the first concerns the expressive function of organizational form, as revealing something about the scope and perceived importance of the policy field, while the second interrogates the policy‐shaping role of organization and the political influence of the federal health ministry in health policy‐making. The article thus considers the organizational location of health issues in the central executive from the perspective of what it reveals about government goals and priorities. Then it examines possible policy implications. It looks at resources and the size of the ministry as a first attempt to learn something about the ministry's political weight. The question of policy implications draws our attention away from organization and resource allocation and back to a focus on policy‐making and policy outcomes. The final section therefore examines substantive policy implications that might have emanated from the organizational consolidation of the federal health ministry. It concludes that one such policy implication might be the erosion of the social insurance model as a regulatory idea in health‐care services and financing.     

Management of HIV/AIDS in the Australian federal system

The purpose of this article is to analyse the effect of the federal structure on public health policy in a crisis situation. Federalism has been one of the most important features of the Australian political system shaping AIDS policy because it has created problems with the coordination of policies and has limited the Commonwealth's capacity to introduce a coherent national monitoring, education, protection, testing and legal framework. My main point is that in the situation of crisis, there is a tendency to rely on the political will of the centre. The political will of the federal health department, subsumed by conflicts and difficulties, has not lasted long enough to construct a new, more uniform structure (a uniform surveillance, legal and health acts framework). It can be concluded that while political intervention and political will cannot be overestimated as means of overcoming organizational rigidities in an emergency situation, the need for a framework conducive to rapid and coordinated responses is obvious. The lesson from the AIDS epidemic points to the need for more uniform public health legislation, for more uniform system of recording data on HIV and for more uniform civil liberties legislation.     

COVID-19 and care homes in England: What happened and why?

In the context of very high mortality and infection rates, this article examines the policy response to COVID-19 in care homes for older people in the UK, with particular focus on England in the first 10 weeks of the pandemic. The timing and content of the policy response as well as different possible explanations for what happened are considered. Undertaking a forensic analysis of policy in regard to the overall plan, monitoring and protection as well as funding and resources, the first part lays bare the slow, late and inadequate response to the risk and reality of COVID-19 in care homes as against that in the National Health Service (NHS). A two-pronged, multidimensional explanation is offered: structural, sectoral specificities; political and socio-cultural factors. Amongst the relevant structural factors are the institutionalised separation from the health system, the complex system of provision and policy for adult social care, widespread market dependence. There is also the fact that logistical difficulties were exacerbated by years of austerity and resource cutting and a weak regulatory tradition of the care home sector. The effects of a series of political and cultural factors are also highlighted. As well as little mobilisation of the sector and low public commitment to and knowledge of social care, there is a pattern of Conservative government trying to divest the state of responsibilities in social care. This would support an interpretation in terms of policy avoidance as well as a possible political calculation by government that its policies towards the care sector and care homes would be less important and politically damaging than those for the NHS.     

Informing UK Policy Development on the Regulation of CAM Practitioners: Lessons from Hong Kong?

Public policy discussions on how to regulate acupuncture and herbal medical practitioners have reached a stalemate in the United Kingdom. After considerable activity in the first half of the current decade a wider review of professional regulation has re-opened the discussion as to the most appropriate way to regulate the practice of all health-care practitioners. In the meantime, the public continues to consult complementary and alternative medicine (CAM) practitioners in large numbers and self-medicate with herbal products and other natural remedies, posing challenges for policy-makers as to how to ensure public safety. In the NHS, providers and purchasers struggle to reconcile demands for access to CAM services with their clinical governance requirements. Hong Kong implemented new arrangements for the statutory regulation of traditional Chinese medical practitioners in the 1990s and has experienced the challenges of regulating a large established private market as well as integrating Chinese medicine further into the public health system. This experience is analysed in order to see whether the approach adopted there could address the public policy challenges faced in the UK. The article finds that, despite key cultural and historical differences related to the provision and use of CAM services, the similarities between the health-care systems and the reasons for moves to professional regulation in Hong Kong and the UK provide useful insights into what is happening in the UK in relation to service provision and the relationship with the NHS and the medical profession. These are discussed in the light of current health policy developments in the UK.     

Dialogues or polemics: Social science expertise and welfare reform in Quebec

The development of social assistance and poverty reduction policies has been informed by social scientific knowledge. Social scientists, however, are not of one mind on such matters. They tend to be divided along disciplinary and ideological lines and may even foster political divisions and conflicts. This article draws on the author's experience as an academic policy adviser to the Quebec government to analyse from up close the institutional context that facilitates knowledge utilisation in the policy process. Two reform processes are considered: the first one, between 1995 and 1998, was less collaborative and led to divisions, and the second, between 1997 and 2009, involved more interactions with the civil service and proved more fruitful. In both cases, experts were divided, as were politicians and civil servants, but their capacity to reach a consensus was fostered, in the second case, by better support and collaboration from the government.     

Revisiting History: The Creation of Provinces and the Politics of Social Policy in a Democratic South Africa

The pre‐democracy negotiations between the African National Congress (ANC) and the National Party (NP) established nine provincial forms of government to replace the four provinces of the apartheid era. The nine provinces contrasted with the historical goal of the ANC to create a ‘democratic, non‐racial and unitary South Africa’. The NP wanted nine new provinces to prevent centralized state power under an ANC government and saw possibilities for winning electoral power in the Western Cape. The ANC conceded following political pressure from the Inkatha Freedom Party, which threatened civil war, and a policy shift after examining the German federal governance system. The article analyzes the history, politics, process and outcomes of the establishment of the nine provinces for social policy delivery in South Africa. It explores the contention that the nine provinces re‐fragmented service delivery (although not on a statutory racial basis) and created a system of fiscal decentralization with serious implications for social policy: weakening bureaucratic capacity, institutional capability and political accountability. The provincial governance mechanisms and fiscal institutions created a particular ‘path dependency’ which, 18 years after democratic, rule still impacts negatively on service delivery and more equitable policy outcomes. This is in part due to the undermining of provincial governance mechanisms and fiscal institutions by a significant minority of corrupt and incompetent provincial civil servants. The corruption of these provincial governance mechanisms and fiscal institutions erodes the egalitarian values aimed at creating a non‐racial, non‐sexist, democratic and unitary South Africa which historically underpinned the policy agenda of the ANC. It also has weakened social citizenship on a geographical and ultimately racial basis given the continuing co‐incidence of race and place in a democratic South Africa.     

Standing Up for Health? Health Departments in EU Health Policy Formulation

When are health departments and ministers influential across policies? This article looks for an explanation in the variable ability of the French, German and UK health departments to influence their states' approaches to EU health policy‐making. It proposes that the extent of departmental power within government and the likelihood that the government imposes a single line across all its departments explain the variable success of the three health departments in influencing EU policy – some have voice in their government's overall stance on EU matters, as in the UK, some have the ability to escape central control and pursue their own agendas in Brussels, and some have neither, and sometimes find themselves pursuing overall strategies that conflict with their analyses and preferences, as in France. The framework, using exit and voice, should be generalizable to the overall influence of health or other ministries in general government policy.     

Social health protection in Cambodia: Challenges of policy design and implementation

The Government of Cambodia is implementing ambitious reform initiatives to improve the country's social health protection system. In January 2018, it was announced that the Health Equity Fund (HEF), which is fully subsidized by a joint government‐donor initiative for the reimbursement of user fees for the poor at public health facilities, is to be expanded to some segments of informal workers belonging to associations, as well as to commune and village chiefs. Since 2017, the National Social Security Fund (NSSF) has provided social health insurance for formal economy workers in enterprises with eight employees or more. In January 2018, it was expanded to civil servants and all employees regardless of the size of the enterprise. However, this article highlights that the new ambitious reforms are not accompanied by careful planning as regards funding, service delivery, human resources and institutional design. This article therefore aims to examine key policy issues and challenges for Cambodia's ambitious reform of its social health protection system in terms of resource generation, population coverage, strategic purchasing and governance.     

Local Participatory Democracy in Britain's Health Service: Innovation or Fragmentation of a Universal Citizenship?

A political emphasis upon the devolution of governance and management in the British National Health Service has, since 1997, been paralleled by an apparent concern to reinvigorate patient and public involvement in aspects of planning and decision‐making. A quasi‐communitarian rhetoric and echoes of nineteenth‐century welfare mutualism have accompanied significant reform of arrangements for patient and public involvement. This article considers the degree to which this fusion of normative exhortation and structural reform heralds a marked evolution in the principles and practice of participatory democracy in the planning and governance of health care. The reforms, in historical perspective, appear to constitute a significant extension of the arenas within which citizens can explore and debate issues pertaining to the health service. But selective political recourse to quasi‐communitarian sentiment points to an embryonic policy discourse that links entitlements to obligations on the part of those reliant on the NHS. This may be of considerable significance in a system of health care to which entitlement has, historically, been cast as a right of citizenship.     

District Health Organization

Government policy in the UK has been to provide comprehensive personalized health care to the whole population free at the point of delivery. However, the first major attempt to unify and regionalize the service in 1974 left a number of problems, and a further restructuring of the NHS was required. This article reports on the results of research into the 1982 restructuring. The main feature of this second reorganization was the formation of territorial entities called "Districts", and their organizational subdivision into "Units". The kind and level of work and authority assigned to Districts and Units is discussed. An important fading, seemingly counter to official policy, is the existence of small Districts which operate at the same level as Units of the larger Districts.     

Factors Impacting Market Occupancy of Non‐profit Human Service Organizations in the Public Social Service Market: Focused on an Individual Level

This study aims to experientially verify which factors of non‐profit human service organizations affect market sharing activities in the public social service market. Due to market‐oriented government policies, non‐profit human service organizations, which used to enjoy stable financial resources, are now placed in a competitive position to provide their services. It is necessary to find out which organizational factors give a competitive advantage to various service providers in competition, including profit organizations, and apply them to the management and operation of non‐profit human service organizations. This is how this study started. Independent variables were organizational characteristics (organization age, total budget, number of employees), externally oriented culture (development culture, rational culture), and organizational structure (centralization, formalization), while dependent variables were the number of vouchers and total profits. Data was collected from 35 community welfare centers, rehabilitation centers, and senior centers (163 respondents) in Busan, Korea. Multiple regression analysis was conducted for data analysis. As a result of the analysis, the number of vouchers was found to be affected by development culture (+) and formalization (?), and total profit from voucher business was determined by organization age (?), total budget (+), and number of employees (+). Based on the results, this study suggests that non‐profit human service organizations should have an externally oriented culture and a flexible organization system to hold more market share in the public social service market.     

从市场检验到政府职能转变——北京市公共服务供给模式改革分析

20世纪80年代以来,在"新公共管理"运动的推动下,以英国、新西兰、澳大利亚为代表的一些国家普遍实行了"公共服务市场化"改革。这一改革浪潮席卷世界,并逐步发展成为大多数国家转变政府职能的一种主流模式。实践证明,与传统的政府"自给自足"和"垄断供应"模式相比,以市场检验为标志的公共服务改革大大降低了公共服务供给成本,提高了公共服务效率,改善了公共部门运行绩效,并为充分运用市场力量推动政府改革提供了新的机遇和动力。     

Behavioural insights,nudge and the choice environment in obesity policy

As obesity constitutes a growing health concern over the world, it has also become an important part of public policy agendas. This paper critically analyses the development of the policy debate and measures around obesity in the UK. The paper contributes to the debate by challenging the current individualized nature of nudge policies as the most popular application of behavioural economics to policy. We argue that it may be possible to change the choice architecture of individuals through nudge, but the overall effectiveness of such policies would be limited because the broader social, economic and political architecture shaping individual choices is ignored. The case of the UK provides a good illustration where concrete policy measures are predominantly focused on choice despite growing recognition of the structural determinants of obesity, and the governments are thus able to avoid threatening free markets and existing economic interests. Whilst the recently introduced sugar tax constitutes a certain shift in policy, it clearly remains an exception within the whole policy package.     

Collaboration between Health and Local Authorities: Why is it necessary?

In contrast with current proposals, collaboration with local government was a dominant factor in the 1974 reorganisation of the NHS. Four categories of such collaboration are identified in this paper: the sharing of services; coordination of service delivery; joint planning; and joint prevention. The need for each is discussed in the context of the reorganisation debate and of subsequent events. In essence, the DHSS case for collaboration — and in particular, its emphasis on joint planning — is seen as both a cause of reorganisation and a consequence of the form which that reorganisation eventually took. Emphasis is placed upon the potential role of collaboration as a vehicle for a preventive health strategy and as an important instrument for the development and implementation of major central government policy objectives. Finally prospects for the continuing evolution of joint working are considered in relation to NHS restructuring. It is concluded that the present government's approach to the structure and management of the NHS is likely to undermine its substantive policy objectives especially in the field of community care.     

御书赏赐的文治气象--宋太宗与唐宋御书政治文化的传承和转型

在宋初文治复兴的语境下，宋太宗不断以御书赏赐来传达崇文的政治理念。其御书赏赐的方式由最初效仿和取法唐代到突破唐代的既有模式，逐步建立自己的风格。在飞白书赏赐时，太宗将“当代”的御书故事与唐代的御书典故对应，这透露出他试图复兴由唐代的御书文化所代表的盛世意象的政治意图；而随着宋太宗与词臣们频繁地进行诗词酬唱，他创造性地用御草书诗赏赐翰林学士和两制词臣，这在后人的追念中成了宋初文治昌盛的象征。此外，宋太宗还选择抄录经史故事和儒家经典这些颇有劝谏意义的内容规鉴和引导群臣，并赏赐御书历子给地方官员不断强化皇权与地方的联系。可以说，宋太宗御书赏赐是宋代文化的一个新旧相兼的政治文化传统。