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.     

Garbage‐can Policy‐making Meets Neo‐liberal Ideology: Twenty Five Years of Redundant Reform of the English National Health Service

The garbage‐can theory of decision‐making (Cohen et al. 1972), has been adapted into a perspective on policy‐making, with adaptations of the approach placing notable emphasis upon the health sector (Kingdon 2006; Paton 2006). This article creates an adapted ‘garbage‐can’ framework to help explain each stage of the reform of the English National Health Service (NHS) over the last 25 years. The emergence of the key idea and resultant policy at each stage of reform of the English NHS has been arational and indeed sometimes irrational. Policy has reflected advocacy by policy‐salesmen (Kingdon 2002), proffering ‘solutions’ to ill‐defined problems and answers to unasked questions, and politicians' short‐termist responses at each decision‐point. Yet the garbage‐can alone is not enough: if arationality rules in policy‐making day to day, this does not mean that there is not an overall ideological context, trend or bias in reform. The article also posits that ‘market reform’ has derived from the ideological hegemony of a naive anti‐statism (hostility to a misleadingly defined and often mythological ‘centralist state’) in public services and enthusiasm for market competition rather than any evidence‐based application of pro‐market ideas to health policy. A question arises: how are these two approaches (short‐term arationality and longer‐term ideological bias) combined in explanation of how policy over time is biased in a particular direction while seemingly arbitrary and directionless at each messy decision‐point. The article attempts to combine the insights of a garbage‐can approach with wider explanations of ideological hegemony.     

Quasi-markets in British Health Policy: A Longue Durée Perspective

Quasi‐markets in health care are generally associated with the period 1991–7 in the later years of office of the British Conservative Party. This paper aims to place such claims in a wider framework by exploring definitions of and conditions of success for quasi‐markets over a longer timescale, beginning in the 1930s and ending with the current New Labour government. It suggests a typology of quasi‐markets based on hard versus soft, direct versus indirect and internal versus external forms. It applies these categories and the conditions for success for quasi‐markets to seven historical periods. Both the typologies and the conditions for success of quasi‐markets varied over time, defying a simple linear development, suggesting a more nuanced historical narrative than simple continuity or discontinuity accounts of recent developments provide. Covering such a large topic over a long sweep of time, with the absence of clear evidence for much of the period, necessarily means that verdicts tend to be impressionistic. However, even at this level, the tentative conclusions provide important contextual elements in the debate on quasi‐markets.     

‘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.     

Knit Your Own Without a Pattern: Health Promotion Specialists in an Internal Market

The reforms of the National Health Service in England have given an emphasis to "strategic" approaches to health and health care, in that, ideally, purchasing decisions will be made on the basis of evidence from various forms of "needs assessment". Alongside these reforms a strategic approach to the promotion of health has been set out in the "Health of the Nation" (DoH 1992). However, although the promotion of health is high on the policy agenda, the occupational group of health promotion specialists, whose prime function it is to devise, develop and implement health promotion strategies, have been ignored. Drawing on qualitative interview data with these specialists in both provider and purchasing settings in England this paper argues that thus far the reforms have actually hindered the development of a strategic approach to the promotion of health by health promotion specialists. Three main reasons for this are suggested; a confusion over the most appropriate institutional location for health promotion specialists; a lack of clarity by key actors as to the role and function of health promotion specialists; and the emergence of a model of effectiveness and efficiency which is largely antithetical to the philosophy and practice of health promotion.     

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。     

An Analysis of Taiwanese Immigrants' Health Care Choice – Obamacare or Taiwan National Health Care

Due to recent policy changes in the USA and Taiwan, Taiwanese immigrants residing in the USA face a choice of continuing to receive health care in the USA or returning to Taiwan for treatment care. This study uses a quantitative survey to explore the association between recent health policy changes and the health care choice of Taiwanese immigrants residing in the USA. These findings indicate that there are statistically significant associations between a variety of factors and the Taiwanese immigrants' desire to return to Taiwan for health care under the new national health insurance plan (2nd NHIA). The variables positively associated with a desire to return to Taiwan for health care include the length of domicile and residence required to receive benefits, a nostalgic desire to return to Taiwan, the lower cost of health care in Taiwan, and if the respondents had come to the USA before 1996. The negatively associated variables include having a job in the USA, having a desire to return to Taiwan to live after retirement, the language preference in communications with a doctor, and a preference about the best place to receive dental treatment. The study reveals the dynamics behind the health care decision‐making of Taiwanese immigrants and particularly their choice of whether to seek care in the USA or in Taiwan.     

Ethnic Diversity Policy: Perceptions within the NHS

Ethnic diversity has become an important policy objective for the Labour government, particularly since the publication of the Macpherson Report (1999) . It is projected as a potential means of improving service provision in various policy areas from policing to the business sector. The contention of this article, based on research conducted in the NHS, is that much more thought needs to be given to the shape of ethnic diversity and its operationalization if services are to improve for society as a whole. The current shape of the concept, as perceived by the majority of the interview respondents who participated in the research (all of whom had responsibility for employment decisions within their organizations), promises at best disappointment, and at worst a further peripheralization of minority ethnic issues, for which communities themselves may be held responsible.     

The Management of Clinicians in the National Health Service

The Griffiths Report recommended that doctors be looked on as natural managers in the National Health Service, and recommended that general managers should make renewed attempts to bring clinicians into the management process. Many attempts had been made in the past to commit doctors to management. A survey was conducted of District General Managers in England to find out what mechanisms they are devising to encourage clinicians to become involved in management. The survey results indicate that two mechanisms dominate general management thinking. One method is to increase clinician participation and involvement in discussions of policy and resource use. The other is to allocate budgets to clinicians and to encourage them to become financially accountable for their actions. The latter view is the most commonly held, though it is not clear what precise purpose the budgets are to serve. The paper concludes that the success of devolved budgets as a management tool will depend upon understanding the factors which motivate clinicians.     

Cancer and Health Policy: The Postcode Lottery of Care

Cancer is a major cause of death and ill health, accounting for roughly one in four deaths in the UK. Concern with cancer services was expressed in the 1990s when it was reported that the quality of cancer care was patchy and variable, and clinical outcomes varied in different parts of the country. The Calman‐Hine Report (1995) produced specific recommendations for the reorganizing and reconfiguring of cancer services, but although the Conservative government, which commissioned the report, endorsed its suggestions no additional funding was provided to implement the proposed changes, and consequently there remained variations in provision across geographical areas and between patients with different cancer types. However, since 1997 the Labour government has targeted cancer, appointing a Cancer Tsar, announcing a package of measures to “fight the war against cancer”, including the publication of a National Cancer Plan (2000 ) and with Tony Blair pledging to end the postcode lottery for cancer treatment. This paper explores the concept of the “postcode lottery of cancer care”, why it exists and whether measures taken since the Calman‐Hine Report and the Cancer Plan will address it.     

Political Feasibility Analysis of the New Financing Scheme for the National Health Insurance Reform in Taiwan: An Application of Stakeholder Analysis

This study carries out in‐depth political feasibility analysis of the prospective health financing reform currently taking place in Taiwan. The National Health Insurance (NHI) Program, which was established in Taiwan in 1995, covers virtually all of the island's citizens. Between the years 2001 and 2004, the Taiwanese Government organized a taskforce to carry out the wholesale reform of the NHI program into the so‐called ‘Second Generation NHI Program’. This study is part of the comprehensive review, focusing on the preferences and positions of key policy stakeholders with regard to the financial reform proposals, as well as their network relationships. The approach of stakeholder analysis was employed to conduct this empirical study. The results reveal that the new financing scheme has a certain degree of support from the policy stakeholders participating in this study, and that in particular, the measures concerning equity and sustainability were most welcome. However, controversy remains with regard to the issue of the equitable sharing of contributions. It is clear that there is much strong support for the new scheme amongst the administrative and legislative elite, although the same level of support is not evident amongst the social elite affiliated with employees' associations and welfare groups.     

浅论政府与非政府组织在社会公共服务提供中的关系

福利经济学主流观点认为社会公共服务作为公共物品只能由政府供给。事实上,在众多市场经济国家,非政府组织在社会公共服务的供给中发挥着重要作用,其成长和壮大有其现实和理论背景。相较于对立的、漠视和依赖,政府与非政府组织在提供公共物品和服务领域中更呈现一种互相合作的伙伴关系。     

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.     

Management by Knowledge in Practice – Implementation of National Healthcare Guidelines in Sweden

In the last ten years, the concept of management by knowledge has gained growing attention in Swedish healthcare, as well as internationally. In Sweden, the most prominent example of management by knowledge is the National Guidelines, aimed at influencing both clinical and political decision‐making in the health sector. The objective of this article is to explore the response among four Swedish county councils to the National Guidelines for Cardiac Care (NGCC). Empirical material was collected through 155 expert interviews with the target groups of the NGCC, politicians, administrators and clinical managers. Analysis of the responses to this multifaceted policy instrument was addressed by drawing on implementation theory (Matland 1995) and institutional theory (Oliver 1991). The NGCC are primarily based on the voluntary diffusion of norms. The county councils are a long way from having adapted all the means suggested by the National Board of Health and Welfare (NBHW): explicit prioritization, healthcare programmes and dialogue between the various actor groups. The high degree of ambiguity in the content of the NGCC, the inherent conflict and the multiplicity and uncertainty in the context of the county councils, have often resulted in avoidance and compromise. The strategic responses we observe can be viewed as an attempt to balance multiple constituents and achieve the various internal organizational goals. The ambiguity and conflict inherent in the policy of the NGCC influence the strategic responses made by the organization. The question remains how far management by knowledge can be applied in a political context.     

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 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.     

从艾森豪威尔到卡特：美国文官“高级行政职位”的建立

文章从勾勒美国建立文官高级行政职位的过程入手 ,比较了艾森豪威尔总统建议建立的“高级文官职位”、尼克松总统提出设立的“联邦行政职位”、卡特总统建立的“高级行政职位”的区别和共同点 ,分析了三位总统在改革美国文官制度方面成功和失败的原因。作者认为 ,美国“高级行政职位”的设立 ,实际上涉及到两个非常敏感的关系 ,即 :总统与高级文官之间的关系以及在这一关系背后发挥潜在影响的政治与行政的关系。“高级行政职位”(SES)的设立 ,无论是从行政或政治的角度 ,都加强了总统对文官的控制与监督     

The Organization of Health Policy Functions in the German Federal Government

This article gives an account of the organizational history of the German federal ministry of health (and its predecessors) since the beginnings of public policy intervention in health care. In doing so it analyses the role of ministerial organization and examines the functional and political rationale underlying acts of reorganizing the tasks and resources of federal ministries. This analysis has two sides: the first concerns the expressive function of organizational form, as revealing something about the scope and perceived importance of the policy field, while the second interrogates the policy‐shaping role of organization and the political influence of the federal health ministry in health policy‐making. The article thus considers the organizational location of health issues in the central executive from the perspective of what it reveals about government goals and priorities. Then it examines possible policy implications. It looks at resources and the size of the ministry as a first attempt to learn something about the ministry's political weight. The question of policy implications draws our attention away from organization and resource allocation and back to a focus on policy‐making and policy outcomes. The final section therefore examines substantive policy implications that might have emanated from the organizational consolidation of the federal health ministry. It concludes that one such policy implication might be the erosion of the social insurance model as a regulatory idea in health‐care services and financing.     

城中村已婚流动女性卫生服务需求及政策分析——以昆明市为例

“城中村”是城市化进程中的特殊现象,流动人口多因城中村便宜的住房而聚居于此。笔者调查的城中村社区已婚流动妇女因自身保健知识及居住环境所限,缺乏公共卫生服务的公平性和可及性,严重地影响了流动已婚妇女的健康。本文就更好地实现“城乡统合”、“人人享有卫生保健”提出行政管理的讨论与建议。