Explaining Different Paths in Social Health Insurance Countries – Health System Change and Cross‐border Lesson‐drawing between Germany,Austria and the Netherlands

The issues of ‘policy diffusion’ or ‘policy transfer’ and ‘mutual learning’ have become important topics in comparative research on social policy and health systems. In current debates on explaining reform in ‘Bismarckian’ social (health) insurance systems, however, these issues have been neglected. In particular, the role of ‘negative lesson‐drawing’ in the sense of avoiding mistakes of others has not often been considered. This article compares health system change in Germany, Austria and the Netherlands, three countries with health systems of the social insurance type. In contrast to the existing literature, our analysis stresses that these countries have taken different reform paths since the 1990s. By applying a most similar systems design, we analyze how far cross‐border lesson‐drawing has contributed to health system divergence in the three countries. The empirical basis of the analysis is semi‐structured qualitative expert interviews, a method appropriate for tracing processes of lesson‐drawing. We argue that in order to fully understand the diverging reform trajectories, we need to take into account how political decision‐makers refer to (negative) experiences of other countries. Generally, national driving forces for health system change were at the heart of many crucial reforms during the period studied. Nevertheless, we claim that it was the German bad practice role model that kept the reform paths of Austria and Germany apart in the Austrian health reform discussion between 2000 and 2005.     

Making Markets in the English National Health Service

Many commentators point to the rise of markets in public services such as healthcare. However, the conventional ‘similarity’ thesis has been challenged by the ‘difference’ thesis. This article critiques and extends the analysis of a recent contribution by Jane Gingrich to the ‘difference thesis’ with a more detailed case study of the English National Health Service (NHS). It argues that the text tends to ignore earlier models and other associated variables; provides a rather crude monolithic characterization of ‘left’ and ‘right’; and assumes rather than demonstrates strategic choice. It modifies some of her major conclusions: markets in public services matter (correct); markets vary in profound and important ways (correct, but perhaps in other ways); and partisan politics are central to explaining and shaping markets (perhaps over‐stated). While Gingrich's ‘breadth’ account is persuasive at the macro‐level, some questions arise from a more detailed account of the English NHS. First, it is not certain that Gingrich's typology is based on the most important dimensions. Second, her account tends to under‐state the importance of issues such as the nature of contracts, price competition, regulation and policies such as Private Finance Initiative. Third, it is not clear that the Conservative healthcare market can be characterized as an Austerity Market, and the Labour market as a Consumer‐Controlled Market. Fourth, this static characterization under‐states the degree of change between and within governments. Lastly, it is not clear what type of market the coalition government has introduced, but this hybrid type may be marked more by policy learning than ideology.     

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.     

Attributing Outcomes to Social Policy Interventions – ‘Gold Standard’ or ‘Fool's Gold’ in Public Policy and Management?

In recent years there has been increased interest in outcome‐based social policy‐making and management. The UK has been in the forefront of this movement but similar movements have been identified internationally. This interest in outcome‐based decision‐making has been given particular impetus through the ‘results’‐based movement in evaluation and performance management since the 1980s, which has increased in scope over time, slowly changing its emphasis from cost reduction and measuring outputs to measuring outcomes. This change has been widely welcomed by policymakers, practitioners and academics. However, there is evidence that the reality is often rather less than the rhetoric. Moreover, the ‘attribution problem’ of attributing changes in outcomes to specific social policies has remained a major issue. The conceptual solution of constructing ‘cause‐and‐effect’ models, imported from the policy evaluation field, has only recently become common for operationalising these models. This article outlines the evolution of interest in outcome‐based social policy‐making up to recent times and the growing realization of the importance of the attribution problem. It then outlines both how the ‘cause‐and‐effect’ policy modelling approach can partially tackle the attribution problem, but also its inherent limitations. Lastly, the article uses several case studies in current UK social policy‐making to demonstrate the potential importance of the reasoning embedded within cause‐and‐effect models but also the dangers in policy‐making which adopts this approach without understanding its conceptual basis or in fields where it is inappropriate, given the current state of our knowledge of social policy systems.     

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.     

Externalizing an ‘Asset Model’ of Activation: Creative Institutional Work by Frontline Workers in the Norwegian Labour and Welfare Service

The past two decades have brought significant shifts in Norwegian activation policy towards a joined‐up and employability‐enhancing approach to labour market inclusion in order to promote return‐to‐work despite health problems or disabilities. Utilizing a concept from health promotion, we term this approach an ‘asset model’ of activation. The Norwegian Labour and Welfare Service (NAV) and its local offices are the main agents implementing the new policy. This article aims to investigate the strategies that the frontline workers of NAV engage in, in order to externalize an ‘asset model’ in the adjacent medical field and to the general practitioners (GPs) in particular. We analyze these strategies as forms of creative institutional work – the purposive actions undertaken to change existing presumptions and opinions among relevant actors. We argue that although the new activation policy is not theirs to develop, in order to bring about changes in practice, ‘creating’ institutional work by the frontline workers is required. Our findings show that the frontline workers develop strategies in order to externalize an asset model to the GPs, as part of operationalizing an ‘activation’ reform into practice. We identify four forms of ‘creating’ institutional work undertaken by the frontline workers: ‘defining’ – enacting legislation and regulation in relation to GPs; ‘constructing normative networks’ – creating a more collaborative relationship with the GPs; ‘educating’ – teaching the GPs about the rules and regulations, and the opportunities and assistive measures they can offer to the injured; and thereby also ‘changing normative associations’ of GPs towards the activation policy.     

Parents' involvement in care order decisions: a cross‐country study of front‐line practice

This article examines parents' involvement in care order decision‐making in four countries at one particular point in the care order process, namely, when the child protection worker discusses with the parents his or her considerations regarding child removal. The countries represent different child welfare systems with Norway and Finland categorized as ‘family service systems’ and the USA as a ‘child protection system’, with England somewhere in between. The focus is on whether the forms and intensity of involvement are different in these four countries and whether the system orientation towards family services or child protection influences practice in the social welfare agencies with parents. Involvement is studied in terms of providing information to parents, collecting information from parents and ensuring inclusion in the decision‐making processes. A vignette method is employed in a survey with 768 responses from child protection workers in four countries. The findings do not show a consistent pattern of difference regarding parental involvement in care order preparations that align with the type of child welfare system in which staff work. The goal in each child welfare system is to include parents, but the precise ways in which it is carried out (or not) vary. Methodological suggestions are given for further studies.     

EU Integration and the Transformation of Post‐communist Welfare: Traversing a ‘Quantum Leap’?

While many academic accounts treat post‐communist Europe as just another site of Europeanization with an emphasis on ‘adaptation’ and ‘learning’, this article argues that EU integration and the transformation of post‐communist Europe is a much more complex, volatile and uncertain process; not so much one of adaptation but more a ‘quantum leap’, apparently bypassing the stage of a Keynesian regime. Post‐communist Europe is asked to join an EU agenda that has many features of what Jessop calls the ‘Schumpeterian Workfare Postnational Regime’ (SWPR). In that sense, EU integration of post‐communist welfare is not simply a ‘catch‐up’, it is a complex transformation process whereby, rather than EU Enlargement and Eastern Europe being seen as a threat to ‘Social Europe’, the EU imposes its own ‘social deficit’ and economic hegemony onto Eastern Europe.     

The Rules of the Game: The Politics of National Pensions in Korea

This article explores the conditions in which policy changes occur over time. It studies the institutional pathways taken by national pensions in Korea over an extended period by identifying the key moments which have pushed through their development: initiation (1973), implementation (1988) and reform (1998). Public pensions have developed over time in an incremental fashion, bringing an ever‐growing proportion of the population under their umbrella. What accounts for this development? A number of factors may be at work. The elderly population has rapidly increased; the traditional extended family has increasingly become a nuclear one, meaning that what used simply to be a family issue of protecting the elderly has become a social matter; urbanization and industrialization have resulted in an ever‐growing number of life‐time contingencies such as unexpected income losses. Convincing as these socio‐economic accounts may seem, however, they offer only a snapshot, underscoring the politics of national pensions which stretch over long periods. This article seeks to answer how and in whose interest national pensions come on to the political agenda; how they are framed and defined; and how political actors respond to pressures for national pension reform. In each of the three stages, it is suggested, somewhat different institutional rules have operated. Defining institutional rules as ‘the process of who gets represented in the decision‐making processes’, this article identifies the different institutional rules which have played a pivotal role in the social policy‐making processes.     

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.     

Why Health Care Reform Now? Strategic Framing and the Passage of Obamacare

Economic reform and health care reform were both focal points outlined in President Obama's policy agenda, with increasing pressure to address economic and social insecurity given that President Obama entered office during the Great Recession (2007–09). The Patient Protection and Affordable Care Act (commonly known as ‘Obamacare’) successfully passed in March 2010 in the context of the economic crisis. We argue that the strategic framing of the economic crisis, through reasoning and arguments linking health care reform with economic downfall, is important in understanding the successful passage of Obamacare, and that this is reflected through strategic frames in speeches delivered by the President on health care reform. Health care reform has been successful not in spite of but rather because of the economic crisis of 2008, that allowed President Obama to use a strategic frame focusing on costs and economic problems. The two main frames identified are the ‘market’ and ‘rights’ frames. President Obama's strategic frames specifically surrounding the economic and cost‐containment priority of health care reform are categorized as a ‘market’ frame in this article. He used this frame until the passage of the law in 2010, when the frame shifted to ‘rights’ frames, largely portrayed through anecdotes and focused on the concept of ‘access’ to care rather than the ‘cost’ of care. This is observable through tracking speeches and statements made in support of health care reform between 2009 and 2013.     

‘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.     

Labour Force Participation,Social Inclusion and the Fair Work Act: Current and Carbon‐Constrained Contexts

The notion that employment is a precondition for personal wellbeing and social inclusion is almost sacrosanct in Australian culture. Yet, the working and living conditions of Australia's low paid workers tells a different story. While labour market participation is a cornerstone of the Federal Government's Social Inclusion Agenda, it is recognized that low pay and poor job quality often derail this key objective. Indeed, the difficulty of ‘making work pay’ at the bottom end of the labour market is a social inclusion challenge that has yet to receive the policy or public attention that it warrants. This article considers what the Fair Work Act means for the social inclusion of disadvantaged workers, in the context of wider‐ranging strategies to address low pay. It concludes with some considerations of the challenges that a carbon‐constrained economy is likely to present for labour force participation as a remedy for social exclusion.     

Cash‐for‐care policy in Sweden: An appraisal of its consequences on female employment

In 2008, Sweden introduced a cash‐for‐care benefit consisting of a flat‐rate sum paid by municipalities to parents whose children were between the ages of one and three and who did not use publicly subsidised childcare. The main object of the reform was to increase parents’ ‘freedom to choose’, but the policy was criticised because of its potentially negative effects on gender equality and mothers’ employment. This study focuses on the effects of cash‐for‐care on female employment in Sweden. The study shows that the adoption of this policy had negative effects on female employment, although primarily in rural areas. Cash‐for‐care was abolished in Sweden in 2016. To evaluate the effects that the policy had on female employment during the time it was in place is important as it indicates what may happen if the policy is introduced again.     

Leaving the Nordic Path? The Changing Role of Danish Trade Unions in the Welfare Reform Process

For a long period, Denmark has been labeled a ‘model country’ with a comprehensive welfare state and a successful model of corporatist policy‐making. Danish unions are considered amongst the strongest in the world, and they have for a long time been a distinct part of the political system, and as social partners, they were strongly integrated into decision‐making processes. The analysis of the Danish welfare and labour market policy during the last two decades documents a profound change in the arrangement and in the status of the social partners (especially unions) in the Danish political system. The results show that two important pillars of the Danish model – the social partner basis and the collective trust in partnership – are eroding. Unions are no longer part of the law‐making process and, since 2007, they are formally excluded from the organization of the decision‐making process. Recent developments point at weaker unions that operate more as lobbyists instead of being strong corporatist institutions or part of the decision‐making process. The results of the study are thought‐provoking and the basis for a revised thinking of the Danish and the Nordic model.     

Market stewardship of quasi‐markets by street level bureaucrats: The role of local area coordinators in the Australian personalisation system

With the rise in popularity of market‐based responses to social policy challenges, the stewardship of quasi‐markets or public service markets, is a key concern for governments worldwide. Debates about how to manage quasi‐markets have focussed on high‐level decision‐making processes. However local actors, in particular street level bureaucrats, are a key part of the complex work of managing quasi‐markets. We examine how street level bureaucrats act as local market stewards in a new quasi‐market for disability care, the Australian National Disability Insurance scheme. We find that the street level bureaucrats, known as local area coordinators, act as shapers of local markets but that their contributions are informal and often restricted by formal structures and processes. For example, we found evidence that the use of key performance indicators can disrupt effective local stewardship efforts towards a procedural approach. We conclude that introducing principles of the polycentric governance approach can improve connections between local market knowledge holders and central decision‐making agencies, thereby improving market stewardship and outcomes.     

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.     

Inter‐agency Cooperation and New Approaches to Employability

This article examines the role of inter‐agency cooperation, which is one form of ‘partnership’, in new approaches to employability in the UK. The article articulates a ‘model for effective partnership working’ on employability. This model is applied first in a general review of employability policy and then to discuss case study research on the recent ‘Pathways to Work’ and ‘Working Neighbourhoods’ pilots. It is argued that successful partnerships need a clear strategic focus based on a necessity for inter‐agency cooperation and institutional arrangements that allow for shared ownership, trust and mutualism, and flexibility in resource‐sharing. While some of these factors are apparent in UK employability services, an over‐reliance on contractualism and centralized organizational structures may undermine partnership‐based approaches. Many of the success factors associated with effective partnership working appeared to be in place, even though the role of the Public Employment Service was fundamentally different in each case (as a key actor in implementing the first pilot, but largely withdrawing from the implementation role in the second). The article concludes by outlining the relevance of this model and the case study findings to discussions of the future development of employability policies and related partnership working.     

Health Policy and the Politics of Evidence

National decisions on the drugs, treatments and medical devices that should be funded through public expenditure are a fundamental element of health policy. But despite a political emphasis upon evidence‐based policy, the results of rigorous clinical trials and statistical modelling techniques rarely speak for themselves. So, does the pre‐eminence traditionally accorded to quantitative data in the medical field underpin policy decisions on a consistent basis? Or are more subtle, less transparent characteristics of context and interaction evident in the shaping of attendant decisions? This article considers these questions by drawing on a study of decision‐making in the National Institute for Health and Clinical Excellence (NICE)—an organization established by the British government in 1999 to decide whether selected health technologies should be made available throughout the National Health Service in England and Wales. In broad terms, the findings point to the primacy of arguments based on quantitatively oriented, experimentally derived data but also to a discursive hegemony of clinicians and health economists in mediating, including or debarring more qualitative, experientially based evidence. A more complex, dynamic understanding of policy governance in the field of health technology appraisal—founded on a discursive appropriation of the idea of the “common good”—goes some way to explaining the persistence of this hegemony despite an avowedly inclusive, plural approach to decision‐making.