Why hasn't integrated health care developed widely in the United States and not at all in England?

There have been influential advocates for financing and organizing health care in the United States and England based on the model of integrated health care delivery systems (IHCDSs). Despite good evidence that a few IHCDSs provide high-quality health care economically, such organizations are rare and localized in a few market areas in the United States and are absent in the English National Health Service (NHS). The explanation of why this is so includes various contributory factors: the way the development of the medical profession in each country pursued specialization; the division in British medicine between general practitioners and specialists; and the characteristics that we identify of established successful IHCDSs, which created formidable barriers to entry for a new IHCDS. This explains why currently the most promising organizational developments in U.S. health care are hybrids resulting from vertical integration. In England government policies of an "internal market," as adopted in the 1990s and currently, were and are based on a purchaser-provider split with the objectives that providers would compete and be funded by a system in which "money follows the patient." These policies recognize the division in British medicine, which also means that it is difficult to implement a reorganized English NHS based on high-performing IHCDSs.     

The negative relationships between employee resilience and ambiguity,complexity, and inter-agency collaboration

Employee resilience (ER) is often needed to face demands inherent in public sector work. Some types of demands, however, may hinder its development, rather than provide the type of challenging adversity from which resilience can develop. Public sector job demands have been a long-standing issue for public workplaces and employees but are also growing in salience as organisations face an increasingly variable, uncertain, complex, and ambiguous environment. Drawing on the Job Demands–Resources model and the challenge/hindrance stress literature, this multi-level study of Aotearoa New Zealand civil servants (n = 11,533) in 65 public sector organisations shows that ER is negatively affected by demands such as job insecurity, unclear job and organisational goals, and inter-agency collaboration. However, organisational resource constraints are positively associated with ER. This study identifies core PA job and organisational demands that hinder ER and offers practical implications and suggestions for further research.

Points for practitioners

• Job role ambiguity, job insecurity, unclear organisational goals, and inter-agency collaboration are common job and organisational demands in public sector workplaces.
• For employees, these demands are stressors that employees do not feel they control, and may therefore hinder employee resilience: the ability to learn, adapt, and leverage networks in the face of challenges.
• Surprisingly, resource constraints, where employees have to ‘do more with less’, might help employees develop ER.
• While inter-agency collaboration has potentially many benefits, it appears to have negative spillover effects on employees unaware of it or not involved in it.
• To encourage ER, agencies should clarify both organisational and job goals, and assure job security, control, competency development, and supervisor support.