Devolution and Centralism in the National Health Service

The reforms to the NHS following the White Paper, Working for Patients, were presented by the Conservative government as promoting devolution, defined as “decisions … taken at the lowest possible level” by Douglas Hurd (1991) — reflecting a senior Minister's interpretation of the overall policy agenda, including health. It was further claimed that such policies (“reforms in hospitals, in schools and in housing”) were a way to “empower citizens”. This approach was naturally an attempt to present the Conservatives' policy as pro-community and ‘practical’ rather than ‘ideological’ or free-market obsessed. It is worth renewing the debate about whether power and/or responsibility were devolved in the NHS — or, indeed, to the NHS from the Department of Health. Rudolf Klein, in the first edition of his The Politics of the National Health Service (1983), had no sooner pointed to the ‘devolution’ inherent in the 1982 reorganization of the NHS (based on the document Patients First (HMSO, 1981) when the Griffiths Inquiry recommendations were accepted. As a result, he was soon to observe that the pendulum — at that time — had quickly swung back to centralism, an observation reiterated after a few years when The Politics of the National Health Service came out in its second edition (Klein, 1989). In other words, there may be a cycle from centralism to devolution and back, or at least an interpretation of events as such in health policy, which makes a current reassessment timely. Which direction did the NHS Act of 1990 and related initiatives embody?     

英国医疗卫生体系问题与医疗卫生政策改革研究

健康是人们福利的重要组成部分,因此医疗卫生政策和体系是社会政策的重要领域。该项研究从贫穷、低收入和健康之间的关联中评估人们对医疗保健的需要;指出英国存在全科医生、医院医生及公共卫生医生是医疗卫生服务提供的主体;英国在医疗卫生政策改革方面的内容包括:(1)对英国全民医疗体系(NHS)多渠道的财政支持,(2)提高服务质量的机构管理改革,(3)实施提高服务质量的安全、有效、病人中心、及时、效率、和平的原则;英国存在的强大政治集团及其利益影响着改革;政府需要在减少医疗服务中不平等和提供及时有效的服务方面努力。     

‘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.     

A macro‐financial analysis of pension system reforms in emerging Europe: The performance of IRAs and policy lessons for Serbia

The article explores the initial macro‐financial performance of partial pension system “privatizations”— involving privately‐managed individual retirement savings accounts (IRAs) — undertaken in many emerging European countries. Using empirical data for a period of close to a decade, the evidence shows that returns on privately‐managed IRAs have been below the implicit rate of return of public pay‐as‐you‐go (PAYG) systems. High operating costs and undeveloped capital markets are identified as major contributing factors to the failure of privately‐managed IRAs to meet reform expectations. In light of empirical evidence, Serbia is advised to focus on parametric PAYG reforms and to avoid reforms that involve the partial “privatization” of the pension system.     

The Forgotten Anniversary? An Examination of the 1944 White Paper, “A National Health Service”

The 1944 Wartime Coalition White Paper, “A National Health Service”is unlikely to be celebrated among the spate of golden anniversaries of welfare reforms in the 1990s. However, a study of this document may be of interest for two main reasons. First, it has some parallels with the reformed National Health National Health Service of the 1990s and, second, there have been recent calls for a local government-based health service, as was envisaged in 1944. The White Paper is examined in the context of evolving plans for the NHS, and is compared with the actual shape of the NHS as introduced by the Labour Minister of Health, Aneurin Bevan, in 1948. Four themes are drawn out. First, the White Paper should not be seen as the embodiment of a political consensus. Second, a Conservative Health Service would have differed from the NHS in fundamental aspects. Third, the conceptual advantages of a local government-based health service were out-weighed by practical politics. Fourth, although the Labour Party made a difference to the shape of the NHS, that shape did not simply follow from party policy. This implies that medical pressure was successful, to some extent, in defining the limits of the new service.     

The RSA (Revenu de solidarité active) and back‐to‐work incentives in France

Using an inventory of local and/or non‐statutory transfers (droits connexes) in 13 French towns and cities, the article first measures the gains from returning to work for recipients of national, statutory means‐tested benefits (Revenu minimum d'insertion— RMI, and Allocation parent isolé— API) by type of household before 2009. The reforms of national, statutory benefits carried out during the 2000s, especially those affecting the working tax credit (Prime pour l'emploi— PPE), failed to ensure that the recipients of means‐tested benefits always stood to gain financially from returning to work. The effects of the reforms were offset by the effects of other measures. The article then simulates the effects of the introduction of the Revenu de solidarité active (RSA) in place of the RMI in 2009, and takes into account the way that local and/or non‐statutory transfers are modified by increases in national, statutory transfers. We observe that the RSA eliminates the financial disincentives to returning to work for almost all localities and types of household. The article shows that the marginal tax rate of 38 per cent chosen by the government is very close to the upper limit compatible with a back‐to‐work incentive.     

Local Participatory Democracy in Britain's Health Service: Innovation or Fragmentation of a Universal Citizenship?

A political emphasis upon the devolution of governance and management in the British National Health Service has, since 1997, been paralleled by an apparent concern to reinvigorate patient and public involvement in aspects of planning and decision‐making. A quasi‐communitarian rhetoric and echoes of nineteenth‐century welfare mutualism have accompanied significant reform of arrangements for patient and public involvement. This article considers the degree to which this fusion of normative exhortation and structural reform heralds a marked evolution in the principles and practice of participatory democracy in the planning and governance of health care. The reforms, in historical perspective, appear to constitute a significant extension of the arenas within which citizens can explore and debate issues pertaining to the health service. But selective political recourse to quasi‐communitarian sentiment points to an embryonic policy discourse that links entitlements to obligations on the part of those reliant on the NHS. This may be of considerable significance in a system of health care to which entitlement has, historically, been cast as a right of citizenship.     

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.     

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.     

Can complementary pension plans help improve retirement income in the Dominican Republic?

In the 1990s, following the earlier example of Chile, pension system reforms were implemented in a number of Latin American and other countries. These reforms focused on introducing models of pension provision that were fully‐funded and privately managed. Although aspects of these reforms have been positive, for many persons covered by these systems retirement income is not adequate. The development of occupational pension plans may offer an alternative, complementary mechanism to help improve pension adequacy. This article discusses different complementary pension plan models and examines the case of the Dominican Republic. It argues that complementary occupational pension plans may be a viable policy option for this developing country.     

Welfare state dissatisfaction and support for major welfare reform: Towards means-tested welfare or a universal basic income?

This research note investigates how people combine their views on two radically opposing welfare reforms: a universal basic income and a fully means-tested welfare state. Using data from the 2016–2017 European Social Survey, we found that support for transformative welfare reform is rooted in perceptions of the performance of the current system. The preferred direction of reform, however, strongly depends on the specific aspects of the welfare state people are happy or unhappy with. At the country-level, we show that underperforming welfare states—in terms of higher poverty rates and lower social spending—increase popular demand for transformative welfare reform, in either direction. These findings are of crucial importance for ongoing debates about the future of the welfare state.     

Expanding economic protection to the elderly in Latin America

This article addresses the reforms introduced in Latin American pension systems that had the aim of increasing coverage beyond formal‐sector workers. For this purpose, fourteen representative regional experiences are analysed using a taxonomy based on features of the cases examined in terms of design, implementation and results. The findings show that, although the reforms share the goal of expanding coverage, there are significant differences deriving from the context in which they were originally designed, their goals, and the capacity available to implement them. The results are not homogeneous, and it is possible to identify some aspects in which policy decisions can lead to better or worse results.     

The state of the German social insurance state: Reform and resilience

At the core of the German system of welfare provision stand social insurance schemes whose central role contributes to Germany being labelled a social insurance state. In recent decades, Germany has been experiencing major social policy reforms that are often evaluated as paradigm changes. These changes have been reflected in analyses that sometimes even questioned common classifications of the German welfare state. The article sheds light on recent developments that have affected the German system of social insurance. It focuses on four aspects of social insurance: benefits, financing, governance, and coverage. Although confirming many earlier analyses of reforms in detail and sharing assessments of changes such as retrenchment and marketization, the article nevertheless stresses that social insurance remains structurally intact and that the work–welfare nexus underlying welfare provision has been reinterpreted but not surrendered.     

Children against parents? The politics of intergenerational recalibration in Southern Europe

Traditionally, Southern European countries displayed remarkably elderly biased social policy arrangements. This article introduces the notion of intergenerational recalibration to capture reforms aimed at rebalancing the generational profile of Southern European welfare states via the expansion of family policy and social assistance schemes—both monetary benefits and care services—and retrenchment in the field of pensions. Then, it elaborates theoretically on the political dimension of this policy strategy, focusing on the implications of the peculiar combination of expansionary and retrenchment reforms, to advance the hypotheses that domestic politics would prevent the realization of such an agenda, whereas the latter would be favored by a major role of supranational actors, especially the European Union. To test these hypotheses, we systematically analyze policy trajectories in the field of pensions and social assistance in Italy and Spain between the mid‐1990s and 2016. This allows, first, to argue that investment in “pro‐children” measures has not adequately balanced the reduction of pro‐parents expenditure and, second, to question the idea that domestic political incentives to expand “pro‐children” policies are necessarily too weak as well as the “enabling” role of external pressures in pursuing intergenerational recalibration.     

“This rabid fight for survival”: Small NGO manager's experiences of funding reform

This article explores the experiences of small Non‐Government Organisation (NGO) managers who are experiencing significant funding reforms. Drawing on a desk review of the literature, and semi‐structured interviews with managers of small NGOs in a case study site of Glebe, New South Wales, we present some of the issues arising from these new modes of funding governance. Findings revealed that funding is increasingly complex, with variations in timeframe, funder and geographic boundaries. The short‐term nature of funding contributed to NGO managers stating that they have been operating in a “survival” mode characterised by a high‐level uncertainty. Changes to funding regimes have led to a need to seek out future funding, engage in competitive tendering processes and comply with multiple and growing funding reporting requirements – tasks that are time‐consuming and at times stressful. Overall, managers experienced overwhelming funding complexity, which impeded the NGO's ability to focus on the needs of clients — an outcome which is surely antithetical to the aims of the various reforms to funding governance.     

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

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

The Implementation of Medical Audit

As part of the 1989 NHS Review, the government made participation in audit compulsory for the medical profession. Prior to this time, medical audit had been fragmented, implemented by “top-down”initiatives promoted by professional bodies as well as by localized “bottom-up”exercises undertaken by committed individuals. The paper uses evidence gained from four case studies of the implementation of medical audit in acute hospitals post 1989, to argue that during the early stages of policy implementation individualistic tendencies have, to some extent inadvertently, been given their head. This has not resulted in stronger external management of medical activities, as the government appeared initially to intend, but rather in locally determined medical audit activity, focused on technical process and medical management. However examining medical audit in the wider context of the total package of NHS reforms and of concurrent changes in medical management, suggests that medical interests, and the individualism that is characteristic of medical organization, will become diluted and less segregated in the future.     

Choosing Welfare or Losing Social Citizenship? Citizens' Free Choice in Recent Italian Welfare State Reforms

In the past fifteen years, the Italian welfare state has gone through various important reforms. Almost all social policy fields have been significantly challenged by the presence of both national and European constraints, and in different policy fields some fundamental principles of the welfare state have been questioned and changed. The purpose of this article is to present an analysis of the most recent arguments used for welfare state reforms in Italy, focusing in particular on one key question: have the reforms been formulated and implemented in order to increase the freedom of choice of Italian citizens with respect to social protection? After a brief introduction and conceptual clarification, each section of the article will focus on one social policy field (employment, pensions, health care) and discuss the origins and consequences of the reforms with respect to the freedom of choice of citizens. The main argument is that very limited attention has been paid in the national political discourse and reform design to the freedom of choice for citizens in welfare state policies, since other goals (such as cost containment) were much more crucial. The article will end with an overall assessment of the evolution of freedom of choice in the Italian welfare state setting.     

Seventy Years of Privatizing the British National Health Service?

The existence of different and conflicting definitions and different types, but few clear measures, of privatization has contributed to different interpretations of the extent of privatization in the almost 70‐year history of the British National Health Service (NHS). This article aims to examine the extent of privatization in the NHS over successive policy chronologies through the lens of the ‘three dimensional’ approach of the Mixed Economy of Welfare. We find that whilst privatization in the NHS is not new, the generally accepted view that it has increased in recent years appears valid, although precision is difficult due to the lack of a generally accepted typology or measure.