Devolution and Patient Choice: Policy Rhetoric versus Experience in Practice

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK‐wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro‐level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.     

Child Welfare in England: Problems, Promises and Prospects

This paper discusses developments in child welfare services in England in recent years and, particularly, the role and contribution of research. It is shown that a more significant and coherent body of child welfare research has been developed, which has linked formally to the policy process. Research programmes in England have highlighted specific problems in three areas: first, moving away from a narrow focus on child protection to an approach that provides broader family support for children in need; second, the absence of policies relating to services for adolescents; and, lastly, problems in the delivery of residential care for young people. A major programme of reform has been introduced by the new Labour government, consistent with research messages. It is concluded that research has had an impact on the development of child welfare services in England, although influencing the structure of services, social work practice and outcomes for young people are highly complex issues.     

The Politics of (Fractured) Solidarity: A Cross‐National Analysis of the Class Bases of the Welfare State

This article considers the politics of social solidarity from a cross‐national perspective. In the analysis, we rely on four waves of international social survey data for our sample of Western nations, representative of different welfare state traditions. The time span is a 20‐year period and the total country‐wave sample comprises over 40,000 records. While there is popular support for governmental actions to protect citizens in old‐age and sickness, views about the social rights of unemployed citizens are shifting. High‐profile activating labour‐market reforms are reapportioning the burden of risk in society. With the rise of right‐wing populism in Europe and the USA, this article examines how interests change as citizens lose their stake in the means of security – revealing an ever more fragile and fractured social solidarity.     

Bringing Indonesia into the global welfare regime debate: A literature review and future research agenda

Studies on welfare state regimes have been dominated by consideration of rich OECD/European and increasingly East Asian countries/territories, leaving South Asian cases such as Indonesia underexplored. The few existing studies that have explicitly tried to conceptualize the Indonesian welfare regime have resulted in little consensus. To address the resulting lack of clarity, this article reviews scholarly articles relevant to bringing Indonesia into the global welfare regime debate, specifically encapsulating how the country has been classified compared with its East Asia counterparts. Accordingly, we find that existing studies have mainly concentrated on the Indonesian health care and social protection expansion, which has led authors to conclude that this evolution demonstrates Indonesia's transition away from welfare productivism. By contrast, we argue that Indonesia's productivist characteristics have largely prevailed while informal networks, clientelism, strong families, and the limited effectiveness of the civil society movement created a specific social politics in Indonesia. We thus conclude that the causal mechanisms typically attributed to welfare development in more developed welfare geographies, including East Asia, cannot fully explain the evident institutional formation in the Indonesian case. The future research agenda for studying the welfare regimes in Indonesia and other Southeast Asian countries is discussed.     

Demise of the Developmental State? Implications for Social Policy Development in Hong Kong

This paper argues that Hong Kong is now at the crossroads of its journey towards social policy development. While economic development still seems to be the unwavering objective of the Hong Kong government, the demand for democracy and social development can no longer be ignored because of a strong civil society fostered by economic success. The current state of affairs provides a window of opportunity for the Hong Kong government to strengthen its legitimacy through the development of social policy and to promote social harmony through inclusivity in social welfare. The findings from the present empirical survey conducted by the Hong Kong Institute of Asia‐Pacific Studies (HKIAPS) in 2010 demonstrate that Hong Kong people identified social harmony as the main direction for social development, closely followed by economic development, and democracy and freedom. Respondents who chose social harmony as the main goal of social development were more likely to take a step back and find common ground when fighting for their own rights or the rights of society. This paper concludes that these findings reflect the crucial importance of taking social harmony into consideration in the social policy development process.     

“第三条道路”的社会福利主张对我国构建和谐社会的重要启示

在构建和谐社会的过程中,应当吸收、借鉴国内外推行社会福利方面政策的经验。作为引起了20世纪80年代以来世界各国社会福利领域发生重大变化的“第三条道路”强调“无责任即无权利”的新原则,提出了积极的福利政策,主张建设社会投资型国家。其中注重人力资本投资、积极的福利政策和发展公民社会对我国构建社会主义和谐社会提供了重要启示。     

The Dynamics of Welfare Policy‐Making in South Korea: Social Movements as Policy Entrepreneurs*

This paper analyzes the role of social movements in the creation and evolution of a welfare state in South Korea. We begin with a theoretical overview of the existing works on policy change, highlighting concepts such as ideas, policy paradigms, and windows of opportunity. We then examine state institutions, hegemonic policy paradigms, and the specific dynamics of welfare policy‐making during South Korea’s authoritarian period (1961–1987). Next, characterizing the democratic transition in 1987 and the economic crisis of 1997–1998 as “windows of opportunity,” we probe how social movements emerged as “policy entrepreneurs” and played crucial roles in building welfare institutions and promoting welfare policies. In particular, we focus on the role of social movements in legislating the National Basic Livelihood Security Act in 1999 and consolidating fragmented health insurance systems in 2000. We conclude that social movements in democratized South Korea have assumed the role of policy entrepreneurs, filling the vacuum left by the central government and elite bureaucrats in the field of social welfare policy‐making.     

Civil society in Canada: A case study of rural and urban planning contexts

This paper explores the political concept of civil society and its emergence in multi-level rural and urban planning contexts. The first section conceptualizes civil society in the broader context within which it develops and we discuss global civil society to establish the need for a more local and regional focus. We then present considerations for assessing civil society and outline the research approach. The second section presents two case examples: (1) rural civil society in British Columbia, Canada focusing on the socio-political environment that enabled a shift away from conventional top-down, state-led forest management to devolved local control, and; (2) urban civil society in Waterloo Region, Ontario, which illustrates the response of local organizations to the wider socio-economic problems of housing provision in the Region. In both rural and urban contexts, there was longstanding tacit local support for each cause but significant triggers were needed to open policy windows and enable civil society organizations to help shift management ideologies in the forestry and housing sectors. Empowering civil actors through, for example, the devolution of decision making and responsibilities, and the redistribution of resources, helped to foster forms of legitimacy needed for emerging local and regional civil society organizations and networks.     

Direct Payments and Disabled People in the UK: Supply, Demand and Devolution

Direct payments have brought new opportunities for self-determinationand independent living to disabled people in the UK, featuringprominently in government strategy and the 2006 White Paper,‘Our Health, Our Care, Our Say’. However, ten yearsafter direct payments legislation, take-up remains low and implementationvaries greatly. Rates of take-up in England remain more thandouble those in other parts of the UK, raising questions aboutdevolution and equity. This paper presents data from a nationalstudy to examine some of the mechanisms underlying uneven outcomesfor disabled people in different parts of the United Kingdom,with particular reference to the politics of devolved governance.The analysis focuses on scope for interpretations of policy;resources for information and training; the impact of mandatoryduties and targets; extensions to new user groups; and the roleof support organizations and disability activism. The evidencesuggests that local variations have been produced not only by‘local’ factors, but also by different opportunitystructures for policy development in England, Scotland, Walesand Northern Ireland. This raises questions about the impactof devolution on equity and opportunity for disabled peoplein the UK.     

State socialism and the welfare state: a critique of two conventional paradigms

The post–war development of industrialised nations has been led by the idea of a welfare state. On the other hand, research on current and former communist states is still dominated by an age–old notion of 'state socialism'. This article provides a critical assessment of the two conventional paradigms by reviewing their implications within the historical and international contexts. By tracing its ideological roots and contrasting with the changing reality, it is argued that state socialism was misused in representing Marxist guidelines and is outdated in characterising the reforming socialist societies. By emphasising the experience of developing nations the article further challenges the welfare state as the paradigm for studying the general direction of a modern society. Attention is drawn to the study of a general public policy, and the economic state model is revisited for conceptualising the experience of a non–welfare state nation such as China.     

Aging and social welfare in transition: the case of the United States

In the United States at the end of the twentieth century, government policies regarding elderly people appear to be in transition. In part this reflects the traditional American ambivalence between radical individualism and collective assistance - especially in the form of tax-supported public welfare provided through government agencies - for those unable to earn or save for their own support. But in part this reflects new concerns about the growth of welfare "entitlements" for elderly people and the presumed "generational inequity" of public support for the aged at the expense of funds for children and young families. We review 1) the changing demography of the United States elderly population, 2) the complex and ambivalent history of welfare policy in the United States and 3) the evidence for tensions and conflicts between older and younger Americans in the context of politicized "generational inequity" debates, with special attention to changing government health care policies. We conclude that in American society, particularly in terms of federal assistance to the aged, there is considerable public support for current policy measures, and - contrary to the predictions of many - it is not likely that there will be dramatic policy changes in the near future.     

Forced to work and liberated from work

The work-welfare nexus is essential in all social policy regimes. The question is in what situations individuals should be entitled to social welfare benefits and in which situations they should be obliged to work. Social welfare law and administrative practices define mechanisms that separate the deserving poor from people able to work. This article analyses the functions and character of these "separation mechanisms" in Sweden during three periods in history: a) in rural society in the late 19th century; b) in industrial society during the successful years of the Swedish model from World War II until the late 1970s; and c) the present, including the period of welfare retrenchment and reconsideration since the early 1980s. The conclusion is that Swedish social policy has always been strongly work-oriented, but the specific form and content of the work ethic has varied under the influence of different ideologies and handled in different social policy institutions. Under specific conditions the work line has been either generous or restrictive and it has been based on structural attempts to improve the opportunities to work as well as on attempts to strongly pressure the individual to work. The work line of today is seen as an interesting attempt to combine an effort to create good work through improved work conditions and an effort to reinforce elements of work enforcement in the social insurance system.     

Singapore: social development, housing and the Central Provident Fund

The high rates of economic growth and significant improvements in standards of living recorded in East-Asian nations such as Singapore in recent decades has attracted increasing attention from social policy scholars in the industrial countries. Many believe that the experiences of these countries offer useful lessons for the Western welfare states. This article examines social security and housing policies in Singapore and shows how both were an integral part of a wider commitment to promote economic development. The article suggests that Singapore provides a good example of a developmentalist approach to social welfare that successfully harmonises economic and social objectives.     

建构北京市大福利制度的思考

我国现代福利制度体系建立在狭义的社会福利观上,这种小福利观已经不适应我国社会建设的需要,急需调整。要建构面向全球化、面向现代社会的福利制度,必须打破将社会福利等同于民政福利的观念,建设面向全体公民的大福利体制。     

Economic Policy and Social Policy: Policy-linkages in an Era of Globalisation

This article argues that changes in the role of the state in economic affairs will affect the process of social policy. Growing economic integration caused by globalisation now places a greater constraint upon the discretion of the nation state, bringing about a transformation into a more competitive state. States are increasingly having to compete against each other in order to promote competitiveness and attract foreign direct investment (FDI) from international capital markets. This competition influences in turn the social policy formation requiring the redesigning of social policy. Thus, welfare states may need to reform their social policy towards a "business-friendly social policy". The analysis of social policy inputs and outputs presented here suggests that there are common trends in most welfare states towards: a market-conforming policy on business taxation, a reduction of the share of employer's contributions in social protection revenues, more limited income security programmes, an increased allocation of resources for active labour market programmes and less state intervention in the labour market. All these reforming trends in social policy can be understood as a response of welfare states to the evolving needs of business caused by structural change, notably globalisation.     

Social Enterprise – A New Phenomenon in the Field of Economic and Social Welfare?

Drawing upon insights from historical institutionalism, this article critically examines the origins of social enterprise and its emergence into the mainstream policy arena. It begins by relating the social enterprise idea to major non‐state/non‐private institutional traditions, including the European social economy, US non‐profits and the UK charitable sector, and places it within the specific field of economic and social welfare. In so doing, the article contests the idea that social enterprise is a new phenomenon in the social welfare field and proposes instead that the supposed ‘novelty’ of social enterprise as an organizational form and a subject of public policy lies primarily in the nature of the socio‐political and economic context of the 1980s–1990s, during which time it became ‘en vogue’. The process of institutionalization of social enterprise and its ascension into the mainstream policy arena is examined in more detail in the case of England during the time New Labour was in office and beyond, and lessons are drawn from this experience concerning both the role that social enterprise plays or is expected to play as a vehicle to address economic and social needs, and how this is intertwined with both a dominant neo‐liberal discourse, as well as alternative perspectives that emphasize more equalitarian and sustainable development paths. The article concludes with some reflections in relation to the apparent consensus that seems to exist around social enterprise as a legitimate subject of public policy and the resulting social enterprization of public services which is currently taking place in England.     

Social work in the making: The state and social work development in China

The instrumental role of government in the development of social work in China has led to questions about its political function. So far, little has been reported on how the government has “made” social work in China. To fill this gap, we first provide a brief chronological review of major policies and activities of the Chinese government in its making of social work in China. The state's intervention has indeed been massive and crucial although, politically, it may limit the mandate of social work in China. Yet, we argue that the development of the social work profession in China is generating institutional space for the emerging civil society to take a more active role in welfare service delivery. Situated and mediating between the state and the emerging civil society, the social work profession in China will need to constantly negotiate its mandate to meet the needs of both sides.     

Welfare state regimes and family policy: a longitudinal analysis

The primary aim of the article is to access the extent to which welfare state regimes support distinct family policies across OECD (Organisation for Economic Co‐operation and Development) countries and over time. Focusing in particular on the work of Esping‐Andersen we address the following questions: (i) What is the relation between de‐commodification and de‐familialisation? (ii) Are there distinct welfare state regimes that support different levels of family policy? (iii) To what extent have levels of support for family policy differed over the last decades toward divergence or convergence among OECD welfare states? Using data from the OECD Social Expenditure database (1980–2001), we find that the degree of de‐familialisation through welfare state regimes parallels the de‐commodification scores. However, the findings indicate a degree of instability in the relationship between levels of support for family policy and welfare state regimes over the last decades. We conclude by discussing how the findings speak to the changing character of welfare regimes and the implications of a longitudinal perspective.     

Devolution in a ‘Stateless Nation’: Nation‐building and Social Policy in Scotland

The implications of the 2011 Scottish election and the proposed referendum on Scottish independence for the future of social policy across the devolved UK are profound but far from certain. It is crucial to understand not only the historical nature of this conjuncture but to develop an adequate conceptual understanding of the place of social policy in the dialectic between state and nation in Scotland. To this end, we critically examine theories that depict Scotland as an essentially ‘stateless nation’ in the light of recent developments. In so doing, we examine the implications for social policy of the changing character of statehood in Scotland, the nature of civil nationalism, and the problem of legitimacy in Scotland for the UK as a multinational state. As the architecture of statehood is re‐negotiated, strong centrifugal pressures are being created for a more distinct divergence of social policy in Scotland from the rest of the UK regardless of the outcome of the independence referendum. Policy‐making is ensnared in a series of tensions, not just between Westminster and Holyrood but also, more broadly, tensions between competing principles of social justice and territorial justice, and competing demands between welfare nationalism and competitive nationalism.     

The Korean welfare state: a paradox of expansion in an era of globalisation and economic crisis

When the Asian financial crisis took a heavy toll on Korea in the late 1990s, policy makers responded by extending welfare policy. For many analysts, this was a paradoxical move, marking a fundamental reconfiguration of the social policy system. This article contests that interpretation. It examines the changes made to Korean social policy in recent years, and considers their impact on the Korean welfare state. It notes both that welfare extensions have been comparatively limited, and that they have often formed part of wider attempts to boost labour market flexibility. It thus concludes that limited expansion of the Korean welfare state is chiefly an attempt to bolster industrial competitiveness and economic growth. For now, Korea retains the productivist social policy orientation that has long characterised it. It also concedes, however, that in the future underlying social change, notably a rapidly ageing population, may prompt policy makers to make significant changes to the Korean welfare state.