Garbage‐can Policy‐making Meets Neo‐liberal Ideology: Twenty Five Years of Redundant Reform of the English National Health Service

The garbage‐can theory of decision‐making (Cohen et al. 1972), has been adapted into a perspective on policy‐making, with adaptations of the approach placing notable emphasis upon the health sector (Kingdon 2006; Paton 2006). This article creates an adapted ‘garbage‐can’ framework to help explain each stage of the reform of the English National Health Service (NHS) over the last 25 years. The emergence of the key idea and resultant policy at each stage of reform of the English NHS has been arational and indeed sometimes irrational. Policy has reflected advocacy by policy‐salesmen (Kingdon 2002), proffering ‘solutions’ to ill‐defined problems and answers to unasked questions, and politicians' short‐termist responses at each decision‐point. Yet the garbage‐can alone is not enough: if arationality rules in policy‐making day to day, this does not mean that there is not an overall ideological context, trend or bias in reform. The article also posits that ‘market reform’ has derived from the ideological hegemony of a naive anti‐statism (hostility to a misleadingly defined and often mythological ‘centralist state’) in public services and enthusiasm for market competition rather than any evidence‐based application of pro‐market ideas to health policy. A question arises: how are these two approaches (short‐term arationality and longer‐term ideological bias) combined in explanation of how policy over time is biased in a particular direction while seemingly arbitrary and directionless at each messy decision‐point. The article attempts to combine the insights of a garbage‐can approach with wider explanations of ideological hegemony.     

Promoting Healthy Routes Back to Work? Boundary Spanning Health Professionals and Employability Programmes in Great Britain

Between 2003 and 2011, the Pathways to Work (PtW) initiative was established across Great Britain, as policymakers sought to address the ‘health‐related, personal and external barriers’ faced by people who were out of work and claiming incapacity benefits (IBs). In the first 18 districts that PtW was rolled‐out, the Public Employment Service (Jobcentre Plus) and National Health Service (NHS) organizations worked in partnership to deliver ‘condition management programmes’, which helped IB claimants to cope with health problems. Evaluation research has identified significant health benefits associated with these condition management programmes, but there has been less discussion of the role of frontline NHS professionals in ensuring that services worked effectively on the ground. This article deploys the concept of ‘boundary spanning’ to explore the role of NHS professionals within PtW. Drawing on more than 50 in‐depth interviews, the article concludes that these NHS staff played a key boundary spanning role in facilitating partnerships, based on an ability to engage with the values/practices of other partner organizations (especially Jobcentre Plus) and a willingness to challenge established professional boundaries and ways of working. The article notes that recent policy initiatives have abandoned the PtW partnership approach in favour of more familiar models of contracting out, and that NHS professionals have been excluded from the delivery of health/employability services. It is argued that these recent changes may negatively affect the quality and range of health‐related services available to people on IBs.     

Varieties of marketisation in the UK: examining divergence in activation markets between Great Britain and Northern Ireland 2008–2014

This article examines the sub-national diversity in activation quasi-markets in the United Kingdom (UK). Through comparison of four active labour market programmes in Great Britain and Northern Ireland between 2008 and 2014, the article clarifies and maps intra-UK diversity in employment service governance and unpacks the shifting configurations of market structures in each jurisdiction to reveal a temporally and spatially distinct patterning of marketisation. Drawing on Gingrich's approach to analysis and classification of quasi-market variation, the article proposes that between 2008 and 2014, Great Britain rapidly evolved a provider-directed activation market. In contrast, the activation market structure in Northern Ireland, up to late 2014, is better characterised as state directed. A recent reconfiguration of the activation market in Northern Ireland does however indicate some (modified) convergence on Great Britain's approach. One common and consistent feature of the configuration of activation markets in each jurisdiction is the few powers given to direct users of employment services to shape contracted out provision.     

‘Creating NHS Local’: The Relationship between English Local Government and the National Health Service

Following recent reforms of both local government and the National Health Service, there is significant emphasis in both services on improving inter‐agency collaboration, user involvement and strategic commissioning. In response, this article reviews historical debates about the relationship between local government and health care, before arguing that these two ‘partners’ need each other now more than ever. If local government is to be a ‘place‐shaper’, then it needs significant influence over local health services, while the NHS needs to learn from the best of local government if it is to gain sufficient local legitimacy to take the difficult decisions it needs to take. Against this background, the article reviews different options for future joint working, exploring various options for enacting a new relationship between local government and the NHS.     

Activation Reform and Inter‐Agency Co‐operation – Local Consequences of Mixed Modes of Governance in Sweden

Organizational reform has become a recurring solution to problems of social exclusion and unemployment. In Europe, and other parts of the world, there is a trend towards policies of ‘activation’ in employment and social policy. The idea of flexible, individualized and tailor‐made services is coupled with managerial and market‐based reforms as well as collaborative governance. In these complex structures of service provision, coordination and inter‐agency co‐operation have become key concerns. Based on a study of a recent reform of programmes for newly arrived refugees in Sweden (Etableringsreformen), this article seeks to contribute to the literature on governance of ‘activation’ by examining the consequences of mixed modes of governance (market and collaborative) on local inter‐agency co‐operation. Drawing on data from in‐depth case studies in two municipalities, it is demonstrated how the coupling of managerial practices and quasi‐markets with existing collaborative arrangements has created barriers for inter‐agency co‐operation. The results indicate that institutional tensions between governance forms represent an important factor for explaining governance failure in this policy area.     

THE RUSH TO REGULATE: THE SHIFT IN AUSTRALIA FROM THE RULE OF MARKETS TO THE RULE OF CAPITAL

There has been a significant shift in the momentum of national economic policy in Australia, from the market as an end in itself, towards a regulated policy agenda that asserts the social, cultural and economic rule of capital. This ‘new’ policy is what neo‐liberalism really involves. Arguments about ‘free markets’ and ‘economic rationalism’ fail to recognise the shift and are thus not germane to current policy analysis.     

Integrated care and the ‘agentification’ of the English National Health Service

Integrated care is a global reform principle for improving patient access and outcomes by ensuring that healthcare organisations deliver services in a joined‐up, person‐centred way. Following reforms designed to infuse agency within English National Health Service (NHS) organisations, the agenda for integration must come to grips with the different approaches to joint working that these organisations mobilise, and the compatibility of their different agentic orientations. We build a matrix for identifying the extent to which different forms of agency orient nine NHS organisational types. Interrogating the Strategic and Operational Plans of these organisations for the period 2015–2018 based on questions derived from the matrix, we associate each organisation with one of eight generalised models. Assuming that there is greater potential for integration where organisations mobilise similar forms of agency, we discuss the incentives and potential governance changes that policy makers might consider to enhance integrative potential.     

Trust and Welfare State Reform: The Example of the NHS

This article discusses the impact of New Public Management on public trust in welfare state institutions, using the example of NHS reform. Discussion of trust in public institutions across political science, psychology and sociology indicates that it is based on both rational/objective considerations (competence and capacity to deliver the service) and affectual/subjective factors (shared values, belief that the trustee shares the trustor's interests). The New Public Management foregrounds individual responsibility and incentives for both suppliers and users of services, in the NHS example in quasi‐markets, management by target and patient choice. These accord with an individualized market rational‐actor model rather than with affective considerations. Analysis of attitude survey data on the NHS confirms that rational/objective and affectual/subjective factors contribute to public trust in this field. However, a comparison between perceptions in England, where the internal market has been vigorously pursued, and Scotland, where the purchaser/provider split was discarded after devolution, indicate that the market does not offer a royal road to perceptions of superior quality in the objective factors. Conversely, the more market‐centred system can make progress in relation to the more subjective affectual factors.     

Organizational Form as a Mechanism to Involve Staff,Public and Users in Public Services: A Study of the Governance of NHS Foundation Trusts

In addition to introducing markets and market‐like structures into public services, New Labour wished to promote the involvement of users and the public in decision‐making in other ways than as individual consumers. One way was to involve the public in the governance of organizations. This could be done by removing public services from state control, and transferring them to mutual ownership; or by increasing public involvement in the governance of public bodies. NHS foundation trusts (FTs) were presented as mutuals. Our study shows FTs are not mutuals, as they continue to be owned by the state. Moreover, staff of FTs were generally not engaging with the new governance structures. In general, there was mixed experience of the new structures enabling governors to increase accountability of the hospitals to the public. On the other hand, having a membership did enhance the legitimacy of FTs, as opposed to other NHS organizations. The findings of the study are of current interest as the coalition government is continuing with the policy of FTs, and also encouraging mutuals and other forms of public involvement.     

Managing professional identity within a changing market environment: New Zealand optometrists’ responses to the growth of corporate optometry

ABSTRACT

This research investigated the effects of changes in the market environment for optometry services and products on the professional identity of New Zealand optometrists. It explored three issues. First, ways participants’ location within either the independent or corporate sectors shaped their professional identities. Second, ways potential ethical conflicts between participants’ healthcare and retailing identities were resolved. Last, participants’ opinions concerning the future of their profession. Twelve male and fourteen female optometrists were interviewed. Nineteen participants worked within independent optometry practices. Seven worked within practices that were part of international optometry chains. Six participants were recent graduates, the rest experienced optometrists. All participants identified primarily as healthcare professionals. All recognised that practising optometry within a commercial market created the possibility of ethical conflicts between healthcare and business imperatives. There were differences in the ways participants managed this boundary, with participants working within corporate optometry seeming more comfortable with the business aspects of their profession. All participants thought the profession was changing and several suggested that the future of independent optometry was limited. The article concludes that recent changes within the market environment of optometry have heightened tensions between optometrists’ medical and entrepreneurial identities and contributed to changing work patterns within the profession.     

Is ‘Candidacy’ a Useful Concept for Understanding Journeys through Public Services? A Critical Interpretive Literature Synthesis

Across the public sector there is concern that service uptake is inequitably distributed by socio‐economic circumstances and that public provision exacerbates the existence of inequalities either because services are not allocated by need or because of differential patterns of uptake between the most and least affluent groups. A concept that offers potential to understand access and utilization is ‘candidacy’ which has been used to explain access to, and utilization of, healthcare. The concept suggests that an individual's identification of his or her ‘candidacy’ for health services is structurally, culturally, organizationally and professionally constructed, and helps to explain why those in deprived circumstances make less use of services than the more affluent. In this article we assess the fit of candidacy to other public services using a Critical Interpretive Synthesis of three case studies literatures relating to: domestic abuse, higher education and environmental services. We find high levels of congruence between ‘candidacy’ and the sampled literatures on access/utilization of services. We find, however, that the concept needs to be refined. In particular, we distinguish between micro, meso and macro factors that play into the identification, sustaining and resolution of candidacy, and demonstrate the plural nature of candidacies. We argue that this refined model of candidacy should be tested empirically beyond and within health. More specifically, in the current economic context, we suggest that it becomes imperative to better understand how access to public services is influenced by multiple factors including changing discourses of deservedness and fairness, and by stringent reductions in the public purse.     

‘Best of Both Worlds’? A Comparison of Third Sector Providers in Health Care and Welfare‐to‐Work Markets in Britain

This article compares the welfare markets in primary health care and ‘welfare‐to‐work’ in the UK since the late 1990s. A longitudinal comparison of two different policy areas enables us to study the context in which marketization and the resulting shift of welfare provision takes place. We outline the general background of the market‐based reforms and highlight in what way policymakers have ascribed third sector organizations (TSOs) a number of positive characteristics, particularly the ability to address concerns about well‐known market failures. While consecutive governments promoted these organizations as welfare providers, case studies of two illustrative provider organizations in each policy area reveal a number of problems regarding their distinctiveness in increasingly competitive welfare markets. We conclude that the crisp distinction made by policymakers between the third and other sectors as well as the alleged advantages of the former present a rather naïve picture of a complex reality and argue for a more critical view of third sector characteristics and performance. The third sector is not only characterized by a high degree of fuzziness at the boundaries to other sectors, but even within single organizations, which often undergo significant transformations over time. As a result, policy intentions and practical outcomes are contradictory with TSOs losing their alleged distinctiveness as players in increasingly competitive markets. Furthermore, we contend that detailed longitudinal studies of organizations are essential in the advancement of the discussion of the third sector concept as they provide conceptual insights into organizational change and behaviour.     

Institutions and the gender wage gap: How production and welfare regime moderates the effect of family policy

The aim of this study was to determine whether the effects of work and family reconciliation policy on the gender wage gap are moderated by institutional contexts of production and welfare regime. Using time‐series analysis for 13 countries from 1981 to 2015, the study revealed a strong association between childcare and a lower gender wage gap in the Coordinated Market Economies (CMEs)/social democratic welfare states but not in Liberal Market Economies (LMEs)/liberal welfare states. The study also found that the impact of leave generosity on the gender wage gap in CMEs/social democratic welfare states is less salient than in CMEs/continental welfare states. This study highlights the extent to which family policy affects the gender wage gap hinges on how each country organises its market coordination and welfare institutions and pushes the current literature forward to a question of ‘what kinds of’ family policy matters in ‘which’ production and welfare regimes.     

‘Replacement Care’ for Working Carers? A Longitudinal Study in England, 2013–15

In the context of rising need for long‐term care, reconciling unpaid care and carers’ employment is becoming an important social issue. In England, there is increasing policy emphasis on paid services for the person cared for, sometimes known as ‘replacement care’, to support working carers. Previous research has found an association between ‘replacement care’ and carers’ employment. However, more information is needed on potential causal connections between services and carers’ employment. This mixed methods study draws on new longitudinal data to examine service receipt and carers’ employment in England. Data were collected from carers who were employed in the public sector, using self‐completion questionnaires in 2013 and 2015, and qualitative interviews were conducted with a sub‐sample of respondents to the 2015 questionnaire. We find that, where the person cared for did not receive at least one ‘key service’ (home care, personal assistant, day care, meals, short‐term breaks), the carer was subsequently more likely to leave employment because of caring, suggesting that the absence of services contributed to the carer leaving work. In the interviews, carers identified specific ways in which services helped them to remain in employment. We conclude that, if a policy objective is to reduce the number of carers leaving employment because of caring, there needs to be greater access to publicly‐funded services for disabled and older people who are looked after by unpaid carers.     

The Civilizing Process of Trust: Developing Quality Mechanisms which are Local,Professional‐led and thus Legitimate

‘Quality’ and ‘performance’ have become defining concepts for policymakers and health‐care systems alike. Yet whilst these principles are of fundamental importance, their practical implementation and assurance are far from straightforward. This commentary analyses the difficulties faced in enhancing quality and performance in the English NHS. Many recent initiatives have been driven through incentives and external auditing of the professionals providing health care on the frontline. Drawing on recent literature and research findings, we argue that this checking‐based ‘audit culture’ is fundamentally flawed in driving quality and performance. Many targets and measures are too crude to reflect important aspects affecting patient outcomes and therefore these frameworks lack legitimacy amongst professionals. An alternative, trust‐based model is proposed – one more capable of acknowledging the meaning, complexity and specificities inherent to professional work. Quality mechanisms developed locally by professionals are able to produce the legitimacy crucial for their effectiveness. It is argued that the normative obligation of approaches based on conditional trust is a more compelling incentive towards good practice than targets and sanctions. This governance by ‘the social’ is able to motivate a more holistically enlightened and consistent reflexivity towards practice, though it is only able to flourish in the absence of purposive‐rational systems.     

New Models of Contracting in the Public Sector: A Review of Alliance Contracting,Prime Contracting and Outcome‐based Contracting Literature

The coordination of public services is an enduring challenge and an important policy priority. One way to achieve collaboration across organizational boundaries, which is being considered in public services such as the English National Health Service (NHS), is through the adoption of alliance contracting, prime provider contracting and outcome‐based contracting. This article reviews the cross‐sectoral literature concerning the characteristics of these new contractual models, how they function, their impact, and their relation to public sector governance objectives. These new contractual forms are characterized as models which, in line with the New Public Management (NPM)/post‐NPM agenda, seek to incentivize providers through the transfer of risk from the commissioners to the providers of services. Key findings are that the models are likely to incur high transaction costs relating to the negotiation and specification of outcomes and rely heavily on the relational aspects of contracting. There is also found to be a lack of convincing cross‐sectoral evidence of the impact of the models, particularly in relation to improving coordination across organizations. The article questions the reconciliation of the use of these new contractual models in settings such as the English NHS with the requirements of public sector governance for transparency and accountability. The models serve to highlight the problems inherent in the NPM/post‐NPM agenda of the transfer of risk away from commissioners of services in terms of transparency and accountability.     

Person‐centredness in the community care of older people: A literature‐based concept synthesis

‘Person‐centredness’ is a ubiquitous term, employed in modern care services to signify policies and practices that attend to the uniqueness of each individual user. Despite being highly regarded in older adult community care services, there is much ambiguity over its precise meaning. Existing reviews of person‐centredness and its attributes have tended to focus on the medico‐nursing literature, neglecting other interpretations, such as those relevant to community social care. A new literature‐based concept synthesis reported here identified 12 common attributes within the broad themes of ‘understanding the person’, ‘engagement in decision‐making’ and ‘promoting the care relationship’. The review also contrasts how these attributes are applied across different interpretations of person‐centredness. The article argues that not all attributes necessarily pull in the same direction, and that older adults may require them to be delivered in different ways than they are to younger people. Thus, a ‘one‐size‐fits‐all’ approach should be discouraged in community care. Key Practitioner Message: ? ‘Person‐centredness’ is open to multiple interpretations, causing difficulties for services trying to gauge performance and quality; ? Three themes are central to person‐centred services: ‘understanding the person’, ‘engagement in decision‐making’ and ‘promoting the care relationship’; ? A ‘one‐size‐fits‐all’ approach to applying person‐centredness is to be discouraged.     

Trust as a Means of Bridging the Management of Risk and the Meeting of Need: A Case Study in Mental Health Service Provision

Shifts in public policy towards an increasing focus on risk have been deemed problematic at a number of levels, particularly the tendency for concerns over reputational risk to institutions to trump the interests and needs of service‐users. This article explores the tension between these two dimensions, of risk and need, in a case study of local mental health services – a setting where conflicting objectives to manage risk and meet need are apparent. Media‐driven pressure to ward against the ‘risk’ represented by service‐users tends towards more coercive policy which may obstruct the meeting of need, which in turn may undermine service‐user engagement and hinder risk management. Drawing on qualitative data from interviews with service‐users, professionals and managers, the article explores the process of trust and its facilitative role in meeting need and managing risk. Findings suggest that while existing foci on risk are at times counter‐productive, trust plays a significant role in service‐users' initial and ongoing engagement, communication and co‐operation with professionals. Yet inherent obstacles to trust within mental healthcare contexts remain, due to cultural pressures on professionals, the nature of the illness experience and negative past experiences of in‐patient care.     

Micro‐provision of Social Care Support for Marginalized Communities – Filling the Gap or Building Bridges to the Mainstream?

As English social care services reconstruct themselves in response to the personalization agenda, there is increased interest in the contribution of micro‐providers – very small community‐based organizations, which can work directly with individuals. These micro‐providers are assumed to be able to cater for the ‘seldom heard’ groups which have been marginalized within mainstream social care services. This article reviews recent literature from the UK published in peer‐reviewed journals from 2000 to 2013 on support provision for people with protected characteristics under the Equality Act 2010. It considers the marginalising dynamics in mainstream, statutory social care support provision, and how far local community, specialist or small‐scale services are responding to unmet need for support and advice among marginalized groups. The review found that there is a tradition of compensatory self‐organization, use of informal networks and a mobilization of social capital for all these groups in response to marginalization from mainstream, statutory services. This requires recognition and nurturing in ways that do not stifle its unique nature. Specialist and community‐based micro‐providers can contribute to a wider range of choices for people who feel larger, mainstream services are not suitable or accessible. However, the types of compensatory activity identified in the research need recognition and investment, and its existence does not imply that the mainstream should not address marginalization.     

Are Quasi‐markets in Education what the British Public Wants?

In the context of inconclusive evidence on the extrinsic successes of quasi‐markets, policy defences of school choice and competition in education have often discussed the intrinsic, empowering value of choice for consumers, arguing that school choice for parents is ‘what people want’. Discourses often imply that choice is desired for its own sake rather than merely as a means by which families can escape what are deemed to be poor quality schools. Support for an idealistic, abstract notion of ‘choice’ is also taken to imply support for quasi‐markets overall and is not considered alongside possible competing values that people may hold at the same time as they value choice. Additionally, views of parents are often examined without considering possible differences in views between parents and non‐parents. Contributing to debates about how far a public desire exists for quasi‐markets in education, this article draws on data from newly designed questions fielded as part of the 2010 British Social Attitudes survey. The article finds that while choice ‘in the abstract’ is supported widely by both parents and non‐parents (albeit slightly more so by parents), a valuing of choice among the British public appears to be more instrumental than intrinsic – potentially problematic given evidence on the extrinsic benefits of quasi‐markets is mixed. Support for choice is tempered among parents and non‐parents by clear opposition to vouchers, school diversity, government spending on transport costs to facilitate choice and by strong support for the idea of sending children to the ‘nearest state school’.