SHOULD THE NATIONAL HEALTH SERVICE HAVE AN INFORMATION STRATEGY?

The National Health Service (NHS) Review committed the NHS to the development of sophisticated information management processes and to the creation of a massive information technology infrastructure, and the success of the new arrangements depends critically upon progress in these two areas. Yet the NHS has a modest track record in both, which the period since the review has served only to highlight. The article examines the political environment in which information is exchanged and technology implemented, in order to explain the current state of play and the likely pace and direction of future developments. In particular it focuses upon the role of the NHS Management Executive in influencing these developments, and argues that success will depend on the extent to which national information policies encourage collaboration between key groups of managers and professionals and support the implementation of contracts for health services.     

Joining it up? Health and Wellbeing Boards in English Local Governance: Evidence from Clinical Commissioning Groups and Shadow Health and Wellbeing Boards

Statutory responsibility for health care and social care has long been separated between National Health Service (NHS) bodies and local government authorities. Repeated policy attempts to promote service integration through collaboration between such authorities have achieved little. The latest of such policy interventions are the Health and Wellbeing Boards (HWBs) established by the 2012 Health and Social Care Act (HSCA) alongside a range of other organisational innovations, including Clinical Commissioning Groups (CCGs). These organisations await full legal and operational status but have begun to develop structures and processes. HWBs are intended to lead the integrated assessment of local needs to inform both NHS health and local authority social care commissioners. We undertook detailed qualitative case studies in eight CCGs during 2011–2012 and here report observational and interview data related to CCGs’ perspectives and observations of early HWB developments. We found that developing HWBs vary greatly in their structure and approach, but we also identified a number of significant issues that are familiar from earlier research into health and social care integration. These include heavy dependence on voluntary agreements to align the strategic plans of the many different new statutory bodies; a significant role for mundane organisational processes in determining the extent of effective co-operation; and problems arising from factors such as size and the arrangements of local boundaries.     

MEMBERSHIP OF THE ‘NEW STYLE’ HEALTH AUTHORITIES: CONTINUITY OR CHANGE?

The 1989 White Paper 'Working for Patients' continued the process begun by Griffiths of managerial reform and the introduction of private sector concepts into the NHS. One of the new proposals was to change the composition and constitution of health authorities, both to avoid the assumed weaknesses of the existing format and to emulate the pattern found in the private sector.
The essence of the change was the removal of the representational elements on authorities, both of medical professionals and nominees from the local authority. The health authorities were reduced in size to just eleven members and for the first time executives were included. Previous attempts at reform within the NHS have been judged to have resulted in more continuity than change. This article examines in detail who the new members are and assesses the balance between continuity and change.
Despite a high level of continuity of membership, there are signs of more fundamental change. There is a significant increase in the proportion of non-executive members from the private sector and with the inclusion of executives, a stronger managerial role is emerging. The article concludes by assessing what the implications of these changes maybe.     

The Changing Nature of Rationing in the UK National Health Service

This paper presents findings from empirical research exploring recent developments in healthcare rationing in the UK, and how far these were influenced by the National Health Service (NHS) internal market. Results suggest explicit rationing has continued to spread, but the focus has shifted from exclusions of whole treatments from NHS provision towards a reconciliation of implicit and explicit approaches. There is growing interest in explicit criteria to guide decision making, within which clinicians exercise discretion in indi-vidual cases. The market contributed to the growth in explicit rationing, notably by decoupling healthcare purchasers (health authorities and GP fundholders) and providers (hospital and community health services) from their previously shared responsibility to manage resources. However, other factors have been influential, especially concern to control rising expenditure. Having originally prompted more explicit decisions (especially exclusions), resource pressures are now rekindling interest in fixed provider budgets and implicit clinical decision making. The paper concludes by considering the implications for rationing of proposals to abolish the NHS internal market.     

Collaborating for Mental Health Services in Wales: A Process Evaluation

The need for inter-agency collaboration between managers of mental health services has long been recognized, as has the difficulty of achieving and maintaining such relationships. Hudson et al . (1999) have developed a model for collaboration in the public sector and the current research has tested the model against attempts to achieve and maintain inter-agency collaboration between mental health managers in Wales. We find Hudson's model a useful analytical framework but our evidence suggests that it needs to be amended by giving greater emphasis to the importance of 'uninterrupted . . . opportunities for interaction' between key managers. Forthcoming changes to NHS structures in Wales (for example, the abolition of Health Authorities and the conversion of Local Health Groups into Local Health Boards) will not necessarily facilitate collaboration if the Local Health Boards are given the role of planning and commissioning mental health services without having the necessary 'critical mass' of knowledge, expertise and dedicated staff capacity for planning and commissioning mental health services.     

COMPLAINTS, REMEDIES AND THE HEALTH SERVICE COMMISSIONER

The Government's Citizen's and Patient's Charters see the Health Service Commissioner scheme playing an important part in securing effective remedies for complaints about administration in the NHS. The scheme is assessed against the background of the fragmented nature of the NHS complaints systems. Because of jurisdictional limitations the Commissioner can only deal with a small proportion of NHS complaints. An analysis of HSC cases between 1986 and 1991 shows that it is those about complaint-handling itself which have been most frequently upheld. The most frequent remedy achieved is an HSC-delivered apology, which is not always found satisfactory, but the HSC places equal emphasis on providing a 'quality audit' and feedback mechanism for health authorities. If the HSC is to play the role implied by the charters, it will be necessary to consider removing the limitations on his jurisdiction which exclude clinical Judgement and the work of family practitioners.     

Legal intervention in civil commitment: the impact of broadened commitment criteria

Recent legal changes in Washington State have broadened the grave-disability criterion for civil commitment of the mentally ill. Analysis of data from state mental hospitals and from records of commitment authorities in Washington's two largest counties revealed that, while there was an increase in the number of involuntary hospitalizations immediately before and after the changes in law, there was a virtual disappearance of voluntary patients in state hospitals. Moreover, expansion of the definition of "grave disability" resulted in a move toward a parens patriae-dominated civil commitment system. Analysis of the empirical consequences of the legal changes on commitment decisions is presented, along with the response of mental health officials and the public.     

Views of public health leaders in English local authorities – changing perspectives following the transfer of responsibilities from the National Health Service to local government

This paper reports on the findings of a research project that examined the changes to the public health system in England introduced in 2013. Drawing on case study research and two national surveys the findings explore the impact of organisational change on the composition and role of public health teams. Views and experiences were obtained from public health leaders involved in the transfer of staff and functions from the National Health Service in England to local authorities. National surveys at two points in time aimed to compare and contrast views on the evolving changes. The new organisational and managerial arrangements had enabled public health professionals to widen their work and influence, and public health skills and budgets were welcomed by those in local government. Initially, in some areas, directors of public health were less certain of the benefits of the transfer to local government compared to high levels of confidence expressed by elected members, but perspectives changed over time and moved closer together. National headline figures were found to mask high levels of turbulence and churn being experienced by individual authorities identified in the case study research, and the trend of reducing capacity through cuts to staff, budget and services was a cause for serious concern.     

THE REGIONAL OFFICES OF THE DOE — POLICEMEN OR MEDIATORS? A STUDY OF LOCAL HOUSING POLICY

The article begins with a review of the existing literature on the regional level of government and the 'regional state', and proceeds to focus on the range of linkages which are found between the centre and local authorities. Seven linkages are identified and after an analysis of the regional level of government it is suggested that professional and technical linkages predominate. The roles of the regional offices of the DOE are then examined within this framework with particular attention being paid to the professional involvement in the housing investment programme negotiations. The article concludes with suggestions concerning the role and influence of the regional officers of the DOE on local authority housing policy.     

RESTRUCTURING GOVERNMENT NEW ZEALAND STYLE

The fourth Labour government (1984–90) has carried out a radical restructuring of executive government comparable to corresonding reforms in Britain. The changes described have been carried out in government Bepartments, state-owned enterprises, the civil service, minister/civil servant relationships, regional and local overnment, and in the organization of the health and education services. The reforms folfow a consistent blueprint based on ideas of economists andublic choice theorists, especially those relating to agency theory and transaction costs. The themes of the New Zealand blueprint are 'decoupling' policy from service delivery, a PrinapaVagent model of managerial decentralization, new financial accounting systems, contracting for service provision and monitoring managerial performance. In implementation, where there are elected authorities but government is the main funding agent, there is uncertainty about the degree of discretion and appropriate accountabilities. Implementation has also illustrated the problems of defining desired outputs and outcomes and in malung them useable by professional workers and elected representatives.     

Power and Public Chambers in the development of civil society in Russia

Embodying a state vision of how civil society ought to function and be designed by the authorities, Public Chambers in Russia have been criticized as means of state control. This state dominance is the starting point in this article, which asks what room to manoeuvre a regional Public Chamber has. Drawing upon fieldwork this article examines how members and local observers of the Public Chamber give meaning to this activity. The analysis assesses the role of state dominance, discussion of routines and responses to local demands, and concludes that these incremental developments form civil society in Russia.     

In the Shadow of the Ombudsman: Civil Society and the Struggle for an Independent Human Rights Institution in St Petersburg,Russia

Abstract

National Human Rights Institutions (NHRIs) have become hallmarks of good governance and democracy. Although many countries have an NHRI, it remains unclear how they operate on the regional level in political systems where democracy malfunctions and human rights are under pressure. Drawing on interviews, this essay examines how Russian nongovernmental organisations (NGOs) established a shadow Ombudsman—the Human Rights Council (HRC)—to protest against the appointment of an Ombudsman in St Petersburg and put pressure on authorities to inaugurate a new and independent Ombudsman. Although we would expect relations between the Ombudsman and NGOs to deteriorate when civil society is under pressure, this essay finds that political repression and the persona of the current Ombudsman, Alexander Shishlov, have brought civil society and the Ombudsman closer together.     

Bureaucracy and implementation of complex tasks in rapidly developing states: Evidence from Indonesia

Political institutions play key roles in rapidly developing states. This article describes the complex and overlapping responsibilities of Indonesian government institutions and explains how they affect policy design and implementation in two policy arenas: primary education and soil/water conservation. It suggests that the struggles for control over local level implementation between general (territorial) regional government and branch offices of specialized, central ministries seriously constrain performance in these two sectors. Dwight Y. King is associate professor of political science and associate of the Center for Southeast Asian Studies, Northern Illinois University, DeKalb, IL 60115 (internet: dking@niu.edu). He continues use research on how the structures of national bureaucracies and the policies governing them affect civil servants’ behavior and economic development, as well as the political economy of bureaucratic reform.     

THE QUASI-MARKET,THE ENTREPRENEUR AND THE EFFECTIVENESS OF THE NHS BUSINESS MANAGER

The recent changes in the UK National Health Service were heralded by the publication of the Griffiths report in 1983 which highlighted the need for a business-like’approach to management. The policy makers’generic strategy of the late 1980s and early 1990s centred around the concept of‘quasi-markets’. These were artificial internal markets encompassing the purchasers and providers of public services. Little research has been undertaken into this new phenomenon of the‘quasi-market’but entrepreneurship economic theory would suggest that for markets to be efficient would require a supply of alert and aware entrepreneurs. Within the restructured NHS, the mantle for entrepreneurial management seems to have been placed firmly on the shoulders of the newly created‘business managers’. A 1993 survey amongst NHS business managers in first and second wave trust hospitals in the Trent Regional Health Authority indicated that whilst business managers were knowledgable of what entrepreneurial activity is, they currently feel constrained in their new roles for a variety of reasons. The authors suggest that rational economic analysis is insufficient to explain this lack of innovatory endeavour. Instead policy makers’attention should be devoted to liberating health managers from their current constraints to encourage their entrepreneurial development.     

PLANS AND PRACTICE: THE PARTICIPANTS' VIEWS

This article is the result of some extensive and lengthy interviews with officers in local and health authorities in two London boroughs. It focuses on their attitudes to resource planning and inter-authority collaboration in the provision of services for two priority groups — the elderly and the mentally handicapped. The interviews were undertaken in 1980, in the aftermath of the tighter financial climate that followed the 1979 election, and fieldwork continued until 1981. Officers' views were tested against models of inter-authority activity drawn from varied literatures. Most officers turned out to have drawn extremely pessimistic conclusions from their experiences. The bureaucratic politics paradigm predominated. Very few participants had come to terms with what planning could mean in a period of declining resources. Most still thought of planning as what to do with the increment and saw little point in planning if there were no increments. However, there were interesting differences between the perceptions of NHS staff and local authority officers, and between those in different kinds of post.     

Bureaucratic Discretion and Political Control of the Resource Conservation Recovery Act (RCRA)

Drawing on theories of political control and bureaucratic discretion this research examines two states' experiences with RCRA implementation and administration in the United States. This research finds that both bureaucratic actors and political actors shape the implementation of these environmental programs with money source and regional EPA offices playing a bigger role than expected.     

Why Deliberate? The Encounter Between Deliberation and New Public Managers

A number of organizations in Britain's National Health Service (NHS) have been experimenting with 'deliberative' techniques of citizen involvement, techniques that were designed with democratic imperatives in mind. However, political practices are moulded by their institutional settings and the goals of their proponents, so it is unlikely that they have been left 'pure' following their encounter with public management imperatives.
This paper offers an explanation for the interest in deliberative processes in the NHS by comparing deliberative and public management imperatives, as well as discussing more case-specific motivations, drawing on interviews with health policy actors between May and July 2001. I then use those insights to highlight gaps between the deliberative ideal and deliberative practice, showing what has been gained and what has been lost in the encounter between deliberative democracy and new public managers.     

The Civil Service Under Stress: The Fall in Civil Service Power and Authority

The failures of governments of both parties in the 1970s had prepared for radical changes in the nature of government under Margaret Thatcher. Among them were that ministers resumed greater power over their civil servants. While various aspects of the relationship between ministers and officials changed and despite the introduction of special advisers, close partnership — the Haldane relationship — was largely retained between them until the end of the 1980s. In the 1990s ministers began to operate less closely with the civil service, largely because they found they had less time for departmental work under the Major and the first Blair administrations. Many of the skills for which civil servants had been trained became less in demand because of the ending of the Cabinet style of government, the reduced importance of ministers appearing before parliament and the greater involvement of spin doctors and media handlers in preparing public documents. However, new skills were required: more rapid accessing of information and more skill in implementation and responsibility for it. The Wilson reforms of 1999 were in large part aimed to remedy these shortcomings. There remains a question whether enough of the Haldane relationship survives for government not to be driven towards greater definition of the rules in which civil servants operate.     

INTERROGATING INSTITUTIONAL CHANGE: ACTORS' ATTITUDES TO COMPETITION AND COOPERATION IN COMMISSIONING HEALTH SERVICES IN ENGLAND

Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers' views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers' understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.