Mental Health Policy in Northern Ireland

Mental health policy in Northern Ireland has moved through a number of phases during the past seventy years. This article examines some of the developments during each of these phases in the context of political factors which had an effect on policy formation and implementation. The services which existed in 1921 were deeply rooted in the lunacy legislation and provision of nineteenth century Ireland. The political uncertainty and financial stringency, which characterized the following two decades, resulted in a situation of almost complete stagnation in those services. The contribution of Northern Ireland during the Second World War guaranteed a financial commitment by Britain to the building of a comprehensive health service in the post-war era. The expansion in mental health services was unprecedented. The relative stability of this era was shattered by the political “troubles” of the 1970s and the imposition of “direct rule” from Westminster. Though advantageous to health service development at first, this has now led to tighter central controls and the further loss of local autonomy. In policies dictated from Westminster, Area Boards moved towards a reduction in psychiatric beds to 1,500—the level of provision in 1870. History tells us that the needs of mentally ill people have not had a significant impact on services in the past. Will the future be any different?     

历史的经验与三峡库区的鼠疫危机

以重庆市为代表的三峡地区,近代以来虽未出发生鼠疫流行,但从中国发生和流行鼠疫的历史经验看,由于三峡水库蓄水后库区鼠类大规模向两侧高地迁徙、库区本身存在的与南方黄胸鼠鼠疫疫源地相同的特征以及南方黄胸鼠鼠疫疫源地再度进入活跃期等因素的综合影响,三峡库区当前和今后一段时间内发生或流行鼠疫的潜在危险是存在的,而且这种危险性还是比较大的。因此,当前和今后数年内,对三峡库区可能发生的鼠疫疫情,必须始终保持高度警惕,并采取切实有效措施,严加防控。     

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.     

Minority government and marginal members: new issues for political and policy legitimacy in Australia

A steady decline in major party support in Commonwealth nations has resulted in changing parliamentary compositions, including the growing prevalence of minority government. Such situations pose new questions for notions of government legitimacy within Westminster systems. For instance, is negotiation with cross-benchers an example of government illegitimacy? What is the legitimate role of non-ministerial members when the composition of parliament gives them the final say on the enabling legislation for public policy? What is the legitimate response of the public sector regarding policy-making in the context of minority government? In this paper, we reflect on how a ‘marginal member’ concept can provide new insights into such issues and their implications.     

The ambiguity of social return policies in the Netherlands

Social procurement policies, which aim to create employment opportunities for vulnerable groups, such as the long‐term unemployed and the disabled, have become increasingly popular in recent years. Despite their growing popularity, empirical research on this topic is limited. Combining insights from the social policy and public administration literatures, we explore the development and implementation of “social return” policies by the Dutch government. These policies are a form of social procurement that require private employers to spend a percentage of public tenders to hire individuals far removed from the labor market. Social procurement appears, by definition, to be a form of social investment. However, our analysis of the ideas underlying its use in the Netherlands suggests that significant contradictions exist, with evidence of neoliberal New Public Management tendencies, social investment, and the more recent form of public administration, New Public Service. Using extensive document analysis of parliamentary documents, discussions and evaluative reports from 2008 to 2014, we reveal the tensions inherent in the Dutch approach and discuss possible implications for our understanding of social policy and administration as well as social protection.     

In the Eye of the Storm: Civil Servants and Managers in the UK Department of Health

In the wake of the 2008 financial crisis, the UK government faces some tough choices over public expenditure, and these choices will have important implications for both the future of health policy and the way in which health services are managed. In this article, we examine the organization and leadership of the UK Department of Health and weigh its suitability to meet such challenges. We find an organization that is culturally split between public servants and managers, highly reliant on the ability of its key personnel to bridge these divides, and extremely responsive to the political goals of government ministers. We explore the modern DH using three types of evidence. First, the history of the department shows clear political efforts to reduce civil service discretion and focus the DH on the management of the English NHS. Second, the recent organizational structures of the DH show a bifurcation between policy direction and NHS management tasks. Third, an analysis of the top ranks of the department since 2005 shows the implementation of political preferences that are consistent with managerialism but inconsistent with the perceived characteristics of traditional civil servants. The result is a department which has changed just as frequently as the health service it oversees – a department which has been moulded by successive ministers into one for the management of the NHS. Our findings raise important questions about the value and purpose of long‐term organizational knowledge in policy formulation.     

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.     

Governing universal health insurance in Korea and Taiwan

This article examines policy responses to the rising costs of healthcare in the Republic of Korea and Taiwan from a governance perspective. It tries to answer why the two countries responded differently to a similar set of challenges facing their National Health Insurance (NHI). While Taiwan – in an attempt to contain costs – introduced a global budgeting system, Korea failed to do so. Governments in both countries attempted to establish a new mode of governance, bringing multiple stakeholders to health policy making in order to build social consensus. But the Korean government, as this article shows, could not resolve its policy deadlock because of a loss of trust between the government and the medical profession, caused by the separation reform of 2001. Even though Taiwan was better able than Korea to address the financial challenges of its NHI, the new mode of health governance is still on shaky ground. This article argues that because neither government now enjoys the exclusive power over health policy that they once did under the developmental state, it is essential to find a way in which different stakeholders can make the necessary compromises that will enable the NHI to run on a sustainable path for the future.     

One new policy: A variety of applications—The implementation processes of a new mental health policy in Sweden

The increase in mental ill health at a global level is widely acknowledged. This trend has led to the development of new policy frameworks that focus on public mental health. This study aimed to explore the implementation process regarding regional and local responses to national policy, proposing a substantially enhanced understanding of mental health within the Swedish welfare system. To explore the implementation process, a multiple case study was conducted using snowball sampling. In all, 18 key informants were interviewed. The results revealed that the informants adopted an experimental implementation process in which policy learning could take place. Contextual factors were essential for how a broad policy approach could be translated into practice. The broad policy not only made it possible for local needs to be addressed, but it also allowed for variations in focus position within the country as a whole. There seemed to be no consensus among the informants as to the origin or solution to the problem. Essentially, the question of whether public mental health issues should be dealt with at a structural or individual level remained unresolved. The Swedish case could be understood as an illustrative example of how one country attempts to handle a major problem despite insufficient information to direct the initiative towards a certain direction.     

政策实施成本与上下级政府讨价还价的发生机制——基于四东县休禁牧案例的分析

讨价还价是中国上下级政府互动关系中很重要的一种形式。本文详细记述了四东县草原休禁牧政策实施过程中上下级政府的多轮讨价还价，县政府制定政策，政策严格落实导致政府与民众的冲突频发，乡镇政府以冲突为策略与县政府讨价还价，最终获得了相对宽松的执行空间。本文使用实施成本分析框架解释了讨价还价行为的发生机制，执行过程成本、上级施加成本、民众施加成本高昂，致使乡镇政府只能选择与上级讨价还价。随着社会冲突的加剧，乡镇政府的讨价还价能力相对提高，使得双方的协议点从严格执行端向宽松执行端移动。执行无僵局、协议点左右摆动、短期均衡与讨价还价的交替发生是政策执行中上下级政府讨价还价的基本特征。     

我国公共医疗卫生政策中的政府角色分析

公共医疗卫生政策关系老百姓的切身利益,近些年来的一系列的天价医疗费事件和医疗改革的成效讨论早已就是人们关注的焦点。本文从当前的热点人手,着重从政策过程角度提出了我国政府在公共医疗卫生政策中的角色定位。     

唐代的蝗灾再认识

唐代蝗灾严重,蝗害导致米价、粟价上涨,导致饥荒,影响士子应举。＂灾异天谴＂说在当时的社会各阶层占有很大的市场。佛教文献中有专门预防、消除蝗害的咒语。当时出现了罕见的食蝗现象。统治者在面对蝗害时,采取了＂祷祈＂之法,当然,皇帝也通过下罪己诏,以正仓、义仓进行赈贷,并遣使者进行慰问,令灾区政府收葬死者、为受灾农民发放种子等措施来救助灾民。一些良吏也在各自境内采取了预防蝗灾、救灾的措施。当时的捕蝗方法主要有焚瘗之法,遣使者捕蝗,出赏钱鼓励民众参与捕蝗。姚崇灭蝗的功绩及焚瘗之法的有效性值得商榷,不过此次捕蝗为后世提供了治蝗的经验。另外,唐代出现了生态灭蝗的现象。     

Minding the minister? Ministerial advisers in New Zealand government

Abstract

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

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

A house divided: deinstitutionalization, medicare and the Canadian Mental Health Association in Saskatchewan, 1944-1964

Defined as a set of distinct processes that included the declining use of large psychiatric institutions and the increasing use of outpatient services and general hospitals, deinstitutionalization occurred earlier in Saskatchewan than other provinces in Canada. It was led by a CCF government dedicated to major change across a number of sectors including mental health, assisted by one of the most influential and well-organized social movement organizations of the 1950s, the Saskatchewan Division of the Canadian Mental Health Association (SCMHA). However, by the late 1950s and early 1960s, the SCMHA opposed the CCF government's policy priority on medicare which it felt came at the expense of mental health care, in particular the implementation of a regional psychiatric hospital system called the Saskatchewan Plan. As a consequence, the SCMHA, once such a powerful ally of the CCF government in health reform, formed a strategic and temporary coalition with the anti-medicare forces in the province. Given the fact that a number of medical staff within the government's department of public health were prominent members of the SCMHA, the CCF government found that it occupied an increasingly divided house at the very time it was struggling to introduce medicare in the midst of civil unrest and a doctors' strike.     

中国村级公共卫生服务供给研究——以政策环境为视角

以政策环境为研究视角,通过对中国村级公共卫生服务供给进行梳理,发现政策执行主体的责任意识得到强化,但也制约了政策实施效果;政策执行客体的满意度及获得感有所增强,但客体也影响了政策有效落地;政策外部环境得到改善,但政策普及任重而道远.为此,提出通过提升政策执行主体的履职能力、加强政策执行客体的认同感、优化政策的执行环境、改善政策的执行手段,以促进村级公共卫生服务供给不断优化.     

The Third Way and Social Welfare: The Myth of Post-emotionalism

The “passive” welfare state was accused of promoting a dependency culture. “Active” welfare and the “what works?” approach of Britain's New Labour government is allegedly implicated in an age of post‐emotionalism, in which people are largely indifferent to the needs of others and committed primarily to their personal well‐being. This article, first, seeks to extend recent debates about agency and motivation in social policy and relate them to the notion of post‐emotionalism. Second, it draws on a recent empirical study of popular and welfare provider discourses, which suggests that popular opinion can accommodate an appreciation of human interdependency, while welfare providers remain committed to a public service ethos. None the less, Third Way thinking is associated with a narrowing of solidaristic responsibilities. The problem for the future of health, social care and state welfare policies lies not with the imagined consequences of post‐emotionalism, so much as with an ideological context that perpetuates a distorted ethic of responsibility.     

Behavioural insights,nudge and the choice environment in obesity policy

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

近代天津的瘟疫流行与慈善机构的医疗救济

近代天津是一个瘟疫多发的城市,尤其是在水旱灾害频发的年份。瘟疫流行期间,天津市各慈善团体均致力于疫病的防治、控制和治疗。他们的善举有效地控制了疫情,拯救了许多人的生命,尤其是士绅倡导的"防疫"理念为近代公共卫生体制的确立提供了市民基础。     

Public Participation in the New NHS: No Closer to Citizen Control?

Over the last decade support for increasing public participation in decisions regarding the planning and delivery of health services has become a familiar feature of the policy agenda for the UK National Health Service. This paper reviews current Labour policy towards public participation and reports on the response of primary care groups (PCGs) to recent Labour directives to make patient and public involvement an integral part of the way they work, presenting the findings of a survey conducted in one English health region. The experience of these PCGs suggests that, despite the diverse backgrounds of board members, there is marked consensus between local and central decision makers as to their understanding of public participation. Whilst academic debates have tended to conceptualize participation in dualist terms as a form of consumerism or of citizenship, the survey data suggest that in the context of local implementation public participation is framed within a new public management perspective which values it as an aid to organizational learning. The findings of this study highlight obstacles to securing effective public participation, including a lack of substantive guidance regarding policy implementation that produces uncertainty amongst local decision makers as to how best to proceed. The inherent limitations of public participation within the new public management paradigm suggest that democratic renewal, one of the goals of the government's modernization agenda, is unlikely to be achieved.     

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.