Making Sense of Inequalities: How Do Clinical Commissioning Groups in England Understand their New Role?

This research explored how newly forming clinical commissioning groups (CCGs) were beginning to think about their new ‘duty’ to tackle health inequalities (HIs), as outlined in UK health policy. The concept of ‘sensemaking’ (Weick 1995) was used to illustrate the influences on CCGs’ interpretations of the policy. Three CCGs in the North of England were recruited, and qualitative methods, including interviews, observations and document analysis, were used to collect data, over a period from January 2012 to December 2012. The tangibility of central policy objectives is important in providing clear guidance and direction to organizations trying to tackle large scale policy agendas such as HIs. At a local level, both individual and collective organizational histories and wider relationships were influential on the way CCGs understood the problem of HIs and how they decided to try to tackle the issue locally. The research highlights what influences local level relationships and what factors need to be considered when trying to interpret and implement national policy at a local level.     

GPs and Contracts: Bringing General Practice into Primary Care

This paper argues that the terms on which GPs entered the NHS, as self-employed contractors, have proved remarkably resistant to the managerial pressures which have come to dominate other sections of the National Health Service. However, this traditional mode of financing and organizing the delivery of a key element of the National Health Service has become increasingly incompatible with wider health policy objectives—the development of an integrated network of good-quality, equitable and well-coordinated primary and community health services which are responsive to local needs. Furthermore, primary health services have themselves come to play a crucially important role in securing other strategic changes in the wider health policy arena, such as securing and sustaining a shift in the traditional balance between hospital and community-based health services and controlling expenditure in a needs-led service. The paper argues that, notwithstanding the change of government, the 1997 NHS (Primary Care) Act and the White Paper "The New NHS" are both integral to the achievement of wider strategic health policy objectives, such as improving the quality and coherence of services, and increasing professional accountability for the financial consequences of clinical decisions. However, the greatest significance of these and other related measures is that they shift the emphasis of health policy from commissioning and purchasing by primary care to commissioning and contracting for primary care. They thereby extend the exposure of GP-based services to managerialist scrutiny and control.     

Opportunities and Risks: Models of Good Practice in Commissioning Foster-Care

Local authorities in Britain have been purchasing foster placementsand related services from independent fostering agencies orproviders (IFPs) for many years. These are often made on anunplanned or ‘spot purchased’ basis and many localauthorities have incurred significant budgetary overspends orbeen criticized for poor child-care practice. In parts of theUSA and Australia, governments have required public authoritiesto ‘outsource’ all or most of their foster-careresponsibilities to private or voluntary agencies. Where thesehave been independently evaluated, a number of deficits havebeen identified. A middle position of local authorities andIFPs entering into service level or contractual agreements hasemerged in Britain where each sector attempts to plan and matchits respective needs and services and to predict and controlcosts. This paper explores how some local authority and IFPmanagers have developed working arrangements with one anotherin order to achieve this position. At a time when the Britishgovernment is providing a strong policy steer towards inter-sectorcommissioning in foster-care, this paper suggests a frameworkfor collaboration.     

Human Motivation and Professional Practice: of Knights, Knaves and Social Workers

Efforts to improve the efficiency and responsiveness of public services by harnessing the self‐interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social services, one way in which British policy‐makers have sought to effect such changes has been through the “new community care” of the 1990 NHS and Community Care Act. Key to this is the concept of care management, in which the identification of needs and the provision of services are separated, purportedly with a view to improving advocacy, choice and quality for service users. This paper uses data from a wide‐ranging qualitative study of access to social care for older people to examine the success of the policy in these terms, with specific reference to its attempts to harness the rational self‐interest of professionals. While care management removes one potential conflict of interests by separating commissioning and provision, the responsibility of social care professionals to comply with organizational priorities conflicts with their role of advocacy for their clients, a tension rendered all the more problematic by the perceived inadequacy of funding. Moreover, the bureaucracy of the care management process itself further negates the approach's supposedly client‐centred ethos.     

Place‐defending and the denial of racism

This paper introduces the concept of place‐defending and articulates its implications for locality‐based social policy. Place‐defending is the protection of one's local area from unfavourable assessments, in this case of being labelled or perceived as a racist space. Place attachment and identifications with place are drivers of place‐defending. Person‐place relationships and their implications for locality‐based social policies have not yet received sufficient consideration in the literature—a significant oversight considering the current policy focus in Australia and the United Kingdom on locality‐based social policy. In this study of local anti‐racism in the Australian context, place‐defending involved the denial of racism and performances of place that reproduced the discourse of tolerance. Print media coverage of the release of national data on racism was analysed alongside a series of interviews with individuals working on anti‐racism at both local and state/federal levels. Four tools of place‐defending are discussed: direct action to defend place; spatial deflections; use of minority group members to discredit claims of racism; and critiques of those who make claims about racism. The tools of place‐defending operated to construct localities as places of tolerance, potentially undermining the case for anti‐racism.     

The Paradoxes of Recovery Policy: Exploring the Impact of Austerity and Responsibilisation for the Citizenship Claims of People with Drug Problems

This article critically examines the implications accompanying the introduction and implementation of recovery‐based policy. The article draws upon research conducted in Lancashire, England, where commissioners have been at the forefront of recent developments in ‘whole system’ models of commissioning. Empirical data are drawn on to make a series of new arguments about the tensions and practice implications of the new recovery agenda. The article has three main objectives. First, it explores current shifts in England, in which drug service commissioning has moved from being centrally funded and directed, to locally determined. Second, it references the rise of the well‐informed user in the reconfigured landscape of recovery and the ways in which commissioning models may enhance or negate the contribution of user activists to local cultures of recovery. Third, it references the changing political context, in which austerity is being used to increase the pressure on provider services to demonstrate social value, utility and effectiveness. The article argues that there is a palpable need to re‐politicize drug debates and recognize the structural and demographic factors which frame problem drug use, as well as the social and cultural factors which support or negate their opportunities for recovery.     

NHS Purchaser–Provider Relationships in England and Wales: The View from Primary Care

Primary care organizations (PCOs) in the National Health Service in England and Wales are required to purchase most hospital-based health care for their populations. This 'quasi-market' in health care can be seen as 'relational', characterized by an emphasis on cooperative long-term relationships rather than on true competition. The English government has recently introduced new market mechanisms as a response to the perceived weakness of the relational market. This article draws on three qualitative case studies of PCOs to investigate whether PCO personnel interviewed in 2005/6 concurred with that perception of weakness. Overall, relationships between PCOs and hospital services providers were regarded as unbalanced in favour of the latter, despite a shared framework of central government policy. Commissioners were seen as generally weak, and providers were judged to be generally unresponsive to PCOs' wishes. Top–down pressure by governments on PCOs and providers of hospital services was more important than commissioning power in shaping hospital services. It remains to be seen whether the remarketization strategy succeeds in strengthening the commissioning function in primary care.     

The Reform of Health Policy in China – Left Behind in the Race to Industrialize?

A major programme of health reform was announced in 2009. China is growing fast, and is beginning to engage with the international social policy community to discuss and review the consequences of rapid industrialization. As a specific part of social policy, health policy shares some of the characteristics of a policy area driven by the consequences of industrialization, but it also has its own particular features. This article reviews the general relationship between state and citizens in the health field by way of an introduction before focussing more specifically on Chinese patterns of health inequalities, and the pressures for reform. The 2009 reform of health policy and its dynamics are then presented, and the article concludes that there has been a deterioration in Chinese health policy, which threatens to undermine the benefits of economic growth for Chinese people.     

Beyond Rhetorical Differences: A Cohesive Account of Post‐devolution Developments in UK Health Policy

Health is perhaps the most significant policy area to be devolved to decision‐makers in Northern Ireland, Scotland and Wales. Consequently, there has been a great deal of interest in assessing the extent to which health policies (which already differed somewhat prior to devolution) have diverged since 1999. To date, analyses have tended to focus either on health care policies or on specific public health issues (e.g. health inequalities or tobacco control). The story that emerges from this body of work suggests health care policies have diverged significantly, whilst public health policies have remained remarkably similar. This article is one of the first to consider health care and public health policy alongside each other. It reassesses and updates previous analyses, incorporating developments relating to the 2010 general election and the 2007 and 2011 devolved administration elections. Drawing on a variety of textual sources (policy documents, research evidence and corporate literature), our findings differ from existing analyses in suggesting that, despite some noticeable differences in policy rhetoric, approaches to both health care provision and tackling public health problems remain similar. Looking to the future, the article concludes that the common economic challenges, combined with a tight fiscal policy (that remains excepted from devolution), means the similarities in health care provision across the UK are likely to remain more pronounced than the differences. However, current debate about the constitutional settlement, and in particular the prospect of greater fiscal freedoms for the devolved administrations, may provide opportunities for more meaningful divergence in health policy than has been possible hitherto.     

Delayed Hospital Discharge and Mental Health: The Policy Implications of Recent Research

In 2003, the Community Care (Delayed Discharges etc.) Act introduced charges for social services departments unable to discharge patients from hospital within agreed timescales. As details of this reimbursement policy have begun to emerge, it has become apparent that the new system may also be extended to mental health services. In response, this narrative review of the literature on delayed hospital discharges and mental health reports findings from 12 studies, which raise important and timely concerns about the feasibility of reimbursement. Although a significant number of people experience delayed discharges from acute psychiatric services, the task of defining delayed discharges is complex and subjective, dependent on the professional background and seniority of the person making the judgement. Reasons behind delayed discharges are also multi‐factorial in nature and cannot be attributed to social services departments alone.     

International Perspectives on the Use of Community Treatment Orders: Implications for Mental Health Social Workers

Substantial changes to mental health law and policy have occurredthroughout the Western world during the last decade. The drifttowards control, particularly in the form of Community TreatmentOrders (CTOs), has profound implications for the role of mentalhealth social workers, yet this issue is rarely discussed inacademic literature. This paper seeks to redress this gap inknowledge by examining aspects of law, policy and practice usingthree case studies: Victoria, Australia; Ontario, Canada; andregions of the UK. The paper begins by critically reviewingselected literature on CTOs, revealing competing claims aboutefficacy and their impact upon service users¹ and practitioners.A discussion of policy and practice contexts in the three jurisdictionsis then presented and supported with a typology, to illustratecontrasts and comparisons. In their conclusions, the authorsassert that mental health social workers often have a crucialpart to play in the implementation of CTOs but that this isnot always acknowledged in law and organizational policy. Socialworkers’ roles and responsibilities need to be more explicitlyidentified in mental health law. At the same time, there shouldbe a continuing debate about how such coercive powers fit withcodes of ethics and practice standards, at national and internationallevels.     

From State Security Model to Selective + Residual Security Model: Health care regime shift in urban China

Based on the study of welfare states, welfare regime theory (WRT) has been widely applied to international and regional welfare regimes and to specific‐policy comparative studies. However, the health care system has often been neglected in this area of study. The current study promotes a health care regime approach that is influenced by WRT and incorporates analysis of the level of health care de‐commodification and health equity. Three types of health care regimes were identified in the development of the health care system in urban China: the State Medical Security Model, the Selective Medical Security Model and the Selective + Residual Medical Security Model. This approach provides useful policy implications for the health care reform currently taking place in China. In addition, this analysis contributes to theories in the comparative health policy literature.     

Policy integration: mapping the different concepts

A growing number of studies have examined the collaboration of actors from two or more policy domains in order to integrate aims and concerns derived from one policy domain into another. In our literature review, we refer to this empirical phenomenon as ‘policy integration’, exemplified by the Health in All Policies approach. Despite the wealth of literature on the subject, the scientific community only has access to a portion of the insights that have come out of this field of research, due primarily to the fact that policy integration is discussed using a variety of different terms, which tend to be specific to the policy domain under investigation. To facilitate a more inclusive scientific debate on policy integration, we provide a comprehensive overview of the different terminologies associated with policy integration and analyse the recurring themes in the respective literature strands. What is the motivation for policy-makers to promote policy integration? What is the design of the instruments used for policy integration? How does policy integration affect the policy-making process? And how well does policy integration perform? These are the four questions guiding our study.     

Tackling and Mitigating Health Inequalities – Policymakers and Practitioners ‘Talk and Draw’ their Theories

In the context of a long‐standing academic acceptance of the socially structured nature of health inequalities, there has been a growing literature that critically examines policies that aim to reduce them. This has demonstrated inadequate policy assessment of the nature of the problem of health inequalities and correspondingly partial solutions that privilege interventions that focus on individual lifestyle solutions over more structural approaches. Much of the research that has been undertaken in this field to explore competing theories of inequalities has analyzed national policy documents or the views of senior policy advisers rather than practitioners. This study uses Raphael’s ‘seven discourses of the social determinants of health’ to understand the implicit theories of health inequalities of both practitioners and policymakers working within a single health care system as they talk about different policy typologies. To help penetrate potentially well‐rehearsed discourses about health inequalities, it tests a visual method of stimulating discussion about how different types of policy might operate to narrow/widen existing gaps in outcomes. Building on Raphael, it finds that individuals’ theories of health inequalities contain co‐existing although not synthesized material and behavioural explanations and that, although the social patterning of material disadvantage was recognized, the role of power and politics is underplayed. Variations between participants did not align with role (policy/practice) and using visual methods to represent the impact of different policy types on health inequalities, though challenging for participants, stimulated reflection about a subject matter that has otherwise become rather stagnant.     

China: Towards the introduction of dependency/long‐term care insurance

The Chinese social security system has been the subject of numerous publications, which have made policy developments more accessible to researchers and administrators from all countries. However, the steps introduced in response to growing demands for intervention by the authorities in favour of dependent persons have remained poorly documented in the international literature. The purpose of this article is to take stock of pilot experiments in this field since the beginning of the 13th Five‐Year Plan (2016–2020) with regard to their policy objective, operating mode and financing modalities.     

The construction of the medical insurance system in the Republic of Korea, 1963–1989

The task of bringing a whole population into medical insurance coverage is a challenging one for a country's health policy makers. The outcomes of health policy differ significantly from one country to another depending on each state's socio-economic and political background. Health policy in Korea is to a great extent incremental in character and the consequence of a variety of causal events. This is why it has been difficult to apply the established social welfare theories to the Korean case. In any event, the Korean national medical insurance system, constructed between 1963 and 1989, reveals some similarity to that in Japan, i.e., compartmentalization of financial and administrative units as well as inequality in contributions and benefits. The system also reflects Korea's traditional Confucian value which emphasizes mutual dependence between family members.     

The State Children's Health Insurance Program: Participation and Substitution

We examine the effects of SCHIP enactment by focusing on two policy concerns: take-up and crowd-out. The literature has examined how income eligibility expansions affect the type of children's insurance coverage. However, states jointly implemented various policy instruments. The results in previous works do not control for this variety. We analyze how changes in several SCHIP factors affected decisions regarding health insurance coverage. Our analysis indicates that the estimates in the literature may have combined the effects of various policy factors. In distinguishing individual policy factors, our results provide useful information for designing effective public health insurance programs.     

The Fiscal Crisis of National Health Insurance in the Republic of Korea: In Search of a New Paradigm

In 2001, National Health Insurance (NHI) in Korea, the social insurance system for health care with universal population coverage, experienced a serious fiscal crisis as its accumulated surplus was depleted. This fiscal crisis is attributed to its chronic imbalance: health care expenditure has increased more rapidly than have insurance contributions. The recent failure in implementing pharmaceutical reform was a further blow to the deteriorating fiscal status of the NHI. Although the NHI has since recovered from the immediate fiscal crisis, this has mainly been because of a temporary increase in government subsidy into the NHI. The strong influence of the medical profession in health policy‐making remains a major barrier to the introduction of policy changes, such as a reform of the payment system to strengthen the fiscal foundations of the NHI. Korea also has to restructure its national health insurance in an era of very rapid population ageing. A new paradigm is called for in the governance of the NHI: to empower groups of consumers and payers in the policy and major decision‐making process of the NHI. The fiscal crisis in Korean national health insurance sheds light on the vulnerability of the social health insurance system to financial instability, the crucial role of provider payment schemes in health cost containment, the importance of governance in health policy, and the unintended burdens of health care reform on health care financing systems.     

A Framework for Exploring the Policy Implications of UK Medical Tourism and International Patient Flows

It is estimated that over 50,000 individuals from the UK each year elect to fund their own treatment abroad. Such treatments commonly include cosmetic and dental surgery; cardio, orthopaedic and bariatric surgery; IVF treatment; and organ and tissue transplantation. The UK has also experienced inward flows of patients who travel to receive treatment and pay out of pocket, being treated in both private and NHS facilities. The rise of ‘medical tourism’ presents new opportunities and challenges in terms of treatment options for consumers/patients and health policymakers. Such developments denote a commercialization, commodification and internationalization of health care in a way that UK policy has not experienced to date. This article addresses four key issues. We explain the rise of medical‐related travel (applied to the UK), identify key policy considerations for the future, highlight important research gaps and explore conceptual frameworks which might help us understand better the observed patterns of medical tourism. Whilst the context for policy and practice is undoubtedly dynamic, we argue the need for greater clarity in understanding the emergent implications for health policy and health care delivery.     

Fat government,thin populace? Is the growth of obesity prevalence lower in more generous welfare states?

In the last few decades, the prevalence of obesity has expanded rapidly and now constitutes a grave public health concern across the developed world. Obesity is negatively associated with, among other factors, education and healthcare quality, which are factors that governments can and do influence through welfare policies. This study investigated to what extent the change in the prevalence of obesity is lower in more generous welfare states. Based on pooled time series cross‐section regressions for 15 developed countries over 25 years, we found that the more generous are transfer payments, health policy and education policy, the lower is the increase of obesity prevalence. These findings have important implications for public policy formation and the public health and welfare state literatures.