Hybridization instead of Clustering: Transformation Processes of Welfare Policies in Central and Eastern Europe

Welfare state theories tend to use concepts of clustering for defining the affiliation of national social security systems to overarching worlds of welfare. A closer look at the transformation processes of welfare policies in Central and Eastern Europe shows a great variability among those countries in approximating their welfare states to Western European standards. In the design of their pension systems, their health care provision and their unemployment protection, Central and Eastern European Countries (CEEC) follow different reform paths. Welfare clusters in Western Europe are used as reference models, but no single example applies to all sectors of social security. Thus, a generalizing picture of welfare provision cannot be drawn for Central and Eastern Europe. Instead of constituting a new individual type of welfare arrangement, a hybridization process is observable.     

Health care in post-crisis South Europe: Inequalities in access and reform trajectories

The European debt crisis stimulated debate about the future of national health systems. The objective of this article is to contribute to this debate by examining any changes in the scope and content of universal coverage and underlying pattern of solidarity in South Europe. Access to health care provides the vantage point for our analysis. Inequalities in access are scrutinized along a number of dimensions by using data from various sources. Our main conclusions clearly show that the public health care systems in Italy and, particularly, in Spain weathered the crisis pretty well and retained their universalistic features. Nonetheless, rising supplemental private coverage (of an “occupational-mutualist” type) adversely impacts access, but it is unclear how this will unfold in the near future. Tackling fragmentation through expansion and equalization of coverage, though for a comparatively “lean” basket of provisions, has been the focus of reforms in Portugal and Greece. This keeps private spending high and sustains inequalities, whereas any prospects for a stronger variant of universalism remain an open question.     

The growth of UK health expenditure

Over the past four decades, spending on health care in the United Kingdom has accounted for a rising share, both of total public spending and of the total output of the economy. Other industrial economies have had similar experiences, although the peculiar nature of the UK health service makes the general explanations offered for such expenditure growth inappropriate. Health spending growth in the UK, for the period 1949–89, is found to be strongly associated with output growth, and reasons to explain this relationship are advanced. The relationship's continued stability in the light of the 1989 health service reforms is questioned.     

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.     

Homelessness in the Czech Republic

This article discusses homelessness in the Czech Republic. In doing so the authors have used an operational definition common in the European Union. In order to explain homelessness in the Czech Republic, the article examines the relevant laws and governmental policies. Then the article discusses some causes of homelessness in the Czech Republic, a recent census of the homeless in the nation, the activities of service-providing organizations, the financing of social services in the nation, health and health care among homeless people, a new food bank, and the harmonization of the Czech Republic with the common objectives of the rest of the European Union .     

Last Chance For The Last Refuge

The theme of this article is the drastic reduction in residential care for the elderly which has met little opposition from within the health and social services despite the growing population of the very aged. The reasons for this professional compliance are examined and found to lie in a combination of mistaken confidence in community care policies and an uncritical acceptance of influential but largely outdated studies whose findings on the adverse effects of institutional care are seriously questioned by later research.     

Solidarity in Italy's policies towards the frail elderly: a value at stake

The Italian public policies towards the frail elderly are underdeveloped by both quantitative and qualitative standards. The bulk of care responsibilities lies on the family and the private provision of paid care is flourishing. The last decade was characterised by significant signs of improvement – an increase in the public resources committed to long-term care and the rising interest of politicians and scholars towards this issue – but the situation is still highly critical. In such a context several questions on solidarity arise regarding the degree to which this value is actually embedded in the public policies, what are the most relevant issues and how the main actors involved are concerned. The article aims to answer some of these questions, taking into consideration the points of view of the main actors: elderly people, carers and professionals.
In doing so, the article discusses the targets of the public services, differences in their provision across the country, the rise of the care allowance and the private provision of paid care. The article shows the problems regarding solidarity in the Italian policies towards the frail elderly and sets an agenda of issues to deal with in the next decade. How policy-makers will be able to manage these issues will determine whether and how the value of solidarity will shape Italy's long-term care policies in the future.     

Social Policy in Greece: Rhetoric versus Reform

This paper reviews the major social policy developments in Greece during the 1980s and 1990s, focusing on social security, health and employment policies. It argues that the concept of social policy and the practice of politics have been distorted in this country. Social policy reflects the legacy of a heavily politicized and centralized policy‐making system, an impoverished administrative infrastructure and poorly developed social services. Its emergence is characterized by the pursuit of late and ineffective policies. It lacks continuity, planning and coordination, being oriented towards short‐term political expediency. It is largely insurance‐based, reproducing huge inequalities and institutional arrangements which are behind the times. It provides mainly cash benefits, low‐quality but rather expensive health services and marginal social welfare protection. Moreover, the lack of a minimum income safety net confirms the country's weak culture of universalism and social citizenship. By implication, complex policy and interlocking interest linkages have tarnished the “system” with a reputation for strong resistance to progressive change. At the same time, sources of change such as globalization, demographic developments, new household and family/gender patterns, unstable economic growth, fiscal imperatives, programme maturation, as well as persisting unemployment, changing labour markets and rising health care costs, have produced mounting pressures for welfare reform.     

Taking Care of Later Life: A Matter of Justice?

Correspondence to: Julia Johnson, Senior Lecturer, School of Health and Social Welfare, The Open University, Walton Hall, Milton Keynes MK7 6AA, UK. E-mail: j.s.johnson{at}open.ac.uk Summary This paper reviews current policies and practices regardingthe provision of long-term care for older people. In particularit focuses on three aspects which are central to social workand care management: current developments in residential andnursing home care; charging for care; and the shifting boundarybetween health and social care. It argues that, in all respects,these policies and the ways in which they are being implementedare incompatible with the notion of social justice. Over thelast fifty years, the older generation has invested heavilyin the welfare state and continues to make a significant contributionto it. The security and well-being of those in need of long-termcare is, however, being threatened by the marketization andcommodification of care provision.     

The Political Construction of Elder Care Markets: Comparing Denmark,Finland and Italy

In Europe over the last two decades, marketization has become an important policy option in elder care. Comparative studies predominantly adopt an institutional perspective and analyze the politics and policies of marketization. This analysis takes a step back and examines the fundamental ideas underpinning the policies of marketization, using the ‘What's the problem?’ approach by Carol Bacchi. The central question is how the market was discursively framed as the solution to the perceived problems of three different systems of elder care, and how such processes are similar or different across the three countries. The analysis includes two extreme types of elder care systems, the Nordic public systems in Denmark and Finland, and the Southern European family‐based model in Italy. Empirically, the analysis offers interesting insights into processes of constructing and legitimating markets at the level of discourse; this occurs by defining specific problem representations, underlying assumptions and silences. In all three countries, marketization is presented as a solution which builds on rather than challenges dominant ideas of care. Conceptually, in addition to its institutions, it is crucial to understand the ideas behind the marketization of elder care. Ideas emerge as a key leverage for making policies and practices of marketization acceptable and which decision makers and other influential political/societal actors use in policy and public debates. The importance of ideas is further underlined by the fact that they do not necessarily relate to the institutions of elder care systems in a linear way.     

Partnership Working and Eligibility Criteria: What Can We Learn from the Implementation of Guidance on Continuing Health Care?

Current government policy places great importance both on clinical governance and on partnership working between health and social services. Separately and together, these policy emphases require greater clarity in and between organizations about who should provide what care where than has often been achieved in the past. A study of the implementation of continuing health care policies suggests that clarity about appropriate long–term health and social care provision was difficult to achieve in the 1990s quasi–markets, because there were too few financial and structural incentives for agencies to cooperate in developing and implementing precise and comprehensive eligibility criteria. This problematic interplay between financial and structural factors is being addressed by a number of government initiatives designed to stimulate joint working, although the difficulty of drawing a clear boundary between health care (free at the point of delivery) and social care (which can be means–tested) remains.     

Cash for care and care employment: (Missing) debates and realities

The introduction of cash‐for‐care (CfC) schemes in different European countries over the last years has responded to a plurality of strategies aimed at attending the rising demand and increasing costs of the long‐term care needs of an ageing population. The specific system of care provision in each country shaped the response given to those challenges, as well as the room for manoeuvre for policymakers when trying to transform the domain of care into a sphere where markets may play a larger role, partly relieving families, and also the state, from these responsibilities. Policy debates and scholarly analyses largely overlooked the contribution of these schemes to the creation and shaping of employment. This article provides a comparative analysis of how CfC‐based policies entail—alongside the regulation of informal care—a(n implicit or explicit) connection with care employment and may contribute to structuring employment relations in this sector. It looks jointly at the specific features of CfC and at the institutional context—welfare regime—in which they are embedded in order to assess the extent to which these schemes contributed (generally unintendedly) to a transformation of the care employment size and features in seven European countries.     

A Social-symbiotic Approach? EU Industrial Policy and the Pharmaceutical Industry in the EU

The purpose of this paper is to develop the debate about a symbiotic approach to industrial policy with respect to the pharmaceutical industry in the EU. The EU has an increasingly important role to play in European markets but it seems, at best, to be following a fragmented industrial strategy. There is a real and growing danger that this strategy becomes worse for everyone than no strategy at all. Thus the EU can either go for a comprehensive and comprehensible strategy or let the industry fend for itself amongst disparate health care systems amongst member states. Alternatively it can continue to stumble along with a pastiche of policies. There are signs of some debate about a more holistic approach to industry. In the European Union for example DG (Directorate General) V and DG III produced a communication arguing that “the [European Union] Community policy in favour of the pharmaceutical industry must take notice of [the] twofold context of public health and social security” (Com(93)718:3). This paper identifies current fragments of EU pharmaceutical industrial policy and indicates what a social-symbiotic approach is. Whether or not the industry in the EU continues to decline with respect to the industry elsewhere Asia and America in particular, the sick people of the EU will still need medication: a symbiotic approach to industrial policy can help stem the relative decline in the EU and indeed could reverse it.     

Reorganizing Social Policies through Social Partnerships: Greece in European Perspective

In postwar Western Europe social policies in the wider sense relied in many countries on neo‐corporatist policies of implementation. Since the 1980s such policies have ceased to be as dominant as they used to be, being associated with what has been called “policy communities” and “policy networks”. As far as the reforms pursued by many countries in order to readjust their economies and labour markets are concerned, significant shifts of such a kind were observed. Illustrations of these trends are presented in a comparative section. We attempt to demonstrate the dual structures of social policy formation and implementation, i.e. neo‐corporatist and network/policy community policies, and to discuss the “how” of such policies, i.e. their “raison d’être” and their “real world” enforcement. Against a background of various semi‐corporatisms and adversarial trade union politics, Greece is trying at the moment to adopt this pattern in several social policy areas, though this is not yet quite visible. Neo‐corporatism is also enhanced. We attempt to show where neo‐corporatism is tried (e.g. certain “social dialogue” structures) and where policy communities are encouraged (e.g. public health, local social policies, etc.). Sometimes the boundaries between the two systems are blurred, with some social dialogue committees appearing as quasi‐policy communities. Finally we endeavour to examine the outcomes of such policies and to see their inner logic against the theoretical background. The concept of multilevel governance as a wider policy instrument which incorporates both the above systems is of special interest here.     

The European Court of Justice and the free movement of patients in the European Union

At present, health policy in the European Union (EU) is being developed in an extremely disconnected fashion. EU member States independently develop their own health systems, based on the goals they wish to pursue, without really considering consistency with European Community (EC) law. The impact of European integration is, in turn, mainly indirect and has emerged from European Court of Justice (ECJ) rulings. These rulings have arisen either from considerations in other sectors or through the process of addressing particular issues within single cases, leaving major issues of applicability unresolved. The evolving issue of free movement of patients is instructive. While not completely outlawing the use of a prior authorization system, recent ECJ rulings have radically restricted member States' discretion to determine their own policies by requiring that their decisions be necessary, proportional and based on objective and non-discriminatory criteria. By linking EEC Regulation 1408/71, on which cover for healthcare abroad has been traditionally based, with the free provision of services, the ECJ seems to have created difficulties and important uncertainties for the system of coordination of social security schemes.     

我国养老机构的地位、性质及运行方式研究

本文从当前养老机构存在的问题入手,通过对服务对象(老人)入住机构的原因和需要的论述,阐明了直接的服务提供主体(养老机构)的地位是长期照顾服务连续体的一个环节,在社会服务体系中发挥托底作用,应该保证较高的服务质量;养老机构在福利社会化的政策背景下兼具福利性和"准市场"性;在运行方式上应该实现各个福利提供主体之间的协调等观点。并通过总结发达国家和地区的相关经验,提出应该明确政府、行业协会、养老机构、市场几个方面的角色地位,协调好相互之间的关系,并注意发展长期性服务项目,进行科学的规划,发展适度普惠型的福利政策等建议。     

‘We Don't Have to Take This’: Zero Tolerance of Violence against Health Care Workers in a Time of Insecurity

Doctors, nurses and other health care workers in the UK are said to be increasingly aware of the ‘risks of the job’ as a result of mounting verbal abuse, threats and assaults from patients and their relatives. In the late 1990s the UK government introduced a policy of ‘zero tolerance’, which it claimed was designed to minimize the risk of such violence. Current policy refers to the need to be tough on offenders and encourage a culture of respect. In this article we review this strategy and the reasons for its introduction and consider some of the potential consequences. The article starts with an account of the policy, the definition of violence that underpins it and how it has been measured, and assesses the evidence regarding prevalence. This is then interpreted in the context of wider policies of zero tolerance to crime, and debates about risk, anxiety and insecurity.     

Organizational Restructuring in European Health Systems: The Role of Primary Care

The main goal of this paper is to review the strategies developed across European health care systems during the 1990s to improve coordination among health care providers. A second goal is to provide some analytical insights in two fields. On the one hand, we attempt to clarify the relationships between pro‐coordination strategies and organizational change in health care. Our main conclusion is that the specific features of health care impede the operation of either market or hierarchical coordination mechanisms. These can, however, be selectively successful if applied as levers to promote the role and impact of the pro‐cooperative coordination strategies which are ultimately required to foster adequate inter‐professional and inter‐organizational coordination. On the other hand, we try to cast some light on the ongoing debate on convergence versus path dependency within the broader field of welfare state reform. Evidence on pro‐coordination reforms in health care apparently supports some insights from previous work on the centrality of the socio‐political structure to account for varying patterns of selective path dependency across countries. In particular, the informal power resources of specialist physicians vis‐à‐vis primary care professionals and the state are critical to explain the different rhythm and fate of pro‐coordination reforms across Europe. Against received wisdom, the evidence examined suggests that selective path dependency might apparently be compatible with a general trend towards convergence understood as hybridization.     

Public Satisfaction with the Health System and Popular Support for State Involvement in an East Asian Welfare Regime: Health Policy Legitimacy of Hong Kong

The legitimacy of social policies has gained increasing attention in the past decade, against the backdrop of fiscal austerity and retrenchment in many nations. Policy legitimacy encompasses public preferences for the underlying principles of policies and the actual outcomes as perceived by citizens. Scholarly knowledge concerning the legitimacy of health policy – a major element of modern social policy architecture – is, unfortunately, limited. This article seeks to extend the scholarly debates on health policy legitimacy from the West to Hong Kong, a member of the East Asian welfare state cluster. A bi‐dimensional definition of health policy legitimacy – encompassing both public satisfaction with the health system and the normative expectation as to the extent of state involvement in health care – is adopted. Based on analysis of data collected from a telephone survey of adult Hong Kong citizens between late 2014 and early 2015, the findings of this study demonstrate a fairly high level of satisfaction with the territory's health system, but popular support for government responsibility presents a clear residual characteristic. The study also tests the self‐interest thesis and the ideology thesis – major theoretical frameworks for explaining social policy legitimacy – in the Hong Kong context. Egalitarian ideology and trust in government are closely related to both public satisfaction with the system and popular support for governmental provision of care. However, the self‐interest thesis receives partial support. The findings are interpreted in the context of Hong Kong's health system arrangements, while implications for the territory's ongoing health policy reform are discussed.     

Access, Choice and Travel: Implications for Health Policy

The UK National Health Service is introducing policies offering patients a choice of the hospital where they would like to be treated. ‘Patient choice’ policies form part of a wider debate about the access to health care and the interaction between providers (including information, provision, performance and reputation) and patients (including knowledge, resources and willingness to travel). As the hospital of ‘choice’ might not necessarily be the ‘local’ provider, such policy developments are predicated on an assumption that some patients will be willing to travel further. This will, in turn, affect patients’ access to services. In general, use of services decreases with distance but this is dependent on accessibility to services, the organization of those services, the socio‐economic characteristics of the patient, perceptions of the provider and the condition for which they are to be treated. This article reviews the evidence on patients’ willingness to travel in terms of access to health care and assesses the emerging implications of and for current UK policy on patient choice.