DOCTORS AND DEFICITS: REGULATING THE MEDICAL PROFESSION IN FRANCE

This paper seeks to analyze the political factors involved in health care delivery in a modern industrial welfare state and to illustrate how the transformation of the French state has affected the policymaking environment surrounding this particular issue. Cultural traditions rooted in the nineteenth century seriously circumscribed the role of the state in de-the conditions of medical practice. Nonetheless, pressures emerging since 1945 for the provision of a wide array of social services have drawn the state into ever closer regulation of the health sector. The economic constraints of the past decade resulted in state-imposed cost-containment policies which accentuated the trend toward politicization of health care. In consequence, and despite the rear-guard defensive tactics of the medical profession, the French state has succeeded in firmly establishing its primacy in this major area of public policy.     

Reframing the rising powers debate: state transformation and foreign policy

Abstract

The volume that we introduce breaks with the prevalent tendency in International Relations (IR) scholarship to treat rising powers (such as China, Russia, India and Brazil) as unitary actors in international politics. Although a neat demarcation of the domestic and international domains, on which the notion of unitary agency is premised, has always been a myth, these states’ uneven integration into the global political economy has eroded this perspective’s empirical purchase considerably. Instead, this collection advances the concept of ‘state transformation’ as a useful lens through which to examine rising power states’ foreign policymaking and implementation. State transformation refers to the pluralisation of cross-border state agency via contested and uneven processes of fragmentation, decentralisation and internationalisation of state apparatuses. The volume demonstrates the significance of state transformation processes for explaining some of these states’ most important foreign policy agendas, and outlines the implications for the wider field in IR.     

BRITISH GOVERNANCE IN TRANSITION: A CASE STUDY OF THE NORTHERN IRELAND CIVIL SERVICE

ABSTRACT

In comparisons of the internal governmental arrangements within states, the United Kingdom (UK) is ordinarily categorised as a unitary state conforming to the ‘Westminster model’. However, this article contends that the changing nature of British governance over the last two decades means that the UK is better viewed as a ‘union state’ that conforms more readily to a ‘differentiated polity model’. Nowhere is the reality of differentiation more clearly exemplif ied than in respect of the British civil service. To illustrate the extent of differentiation, the article presents a case study of the characteristics and trends in the civil service of Northern Ireland for, while the politics of the Province have received great attention, its system of public administr ation has been chronically under-reported. The article considers the changing structures, policy process and impact of public management reforms as well as the restoration of devolved government. Finally, it summarises how the evidence from Northern Ireland informs theoretical understanding as well as its implications for the rest of the UK and beyond.     

INSTITUTIONAL LAYERING IN GOVERNING HEALTHCARE QUALITY

Since the 1980s, regulated markets and New Public Management have been introduced in the public sector across the world. How they have affected existing governance mechanisms such as self‐regulation and state regulation has remained largely unexplored, however. This article examines the origins and consequences of institutional layering in governing healthcare quality. Dutch health care, where a market‐based system has been introduced, is used as a case study. The results show that this market‐based system did not replace but modified existing institutional arrangements. As a result, hospitals have to deal with the fragmentation of quality demands. Using the concept of institutional layering, this study shows how different arrangements interact. As a consequence, the introduction of a certain policy reform will work out differently in different countries and policy sectors. Our ‘archaeological’ study in this layering can be seen as an example of how such incremental change can be studied in detail.     

Analysing Local Policy Agendas: How Dutch Municipal Executive Coalitions Allocate Attention

Abstract

This article provides an analysis of the allocation of attention to policy problems on the local level, focusing on the executive agenda of six municipalities in the Netherlands over a 25-year period. It reveals that there is specifically a local politics of attention, showing differences between national and local policy agendas in specific policy areas. We did not find evidence that the political composition of the local executive coalitions leads to agenda differences, revealing the more problem-oriented and pragmatic nature of local politics. We did find evidence of an effect of institutional arrangements between national and local government on shifting patterns of attention, such as due to decentralisation. This shows that the local politics of attention is limited in scope and conditioned by the functions of local government and the institutional arrangements of policy making in the Dutch decentralised unitary state and that rearrangements affect these patterns of attention.     

CONSULTATIVE PROCESSES IN HEALTH POLICY IN THE UNITED KINGDOM: A VIEW FROM THE CENTRE

Health policy at national level is the product of a series of continuous and complex interactions between interest groups operating both inside and outside government. It is generally thought that these consultative processes are closed, elitist and dominated by the prestigious medical specialties. Yet there has been a rapid growth in the number of groups representing various interests, professions and care groups. Drawing on recent examples from the national health service, the paper explores the extent to which consultative processes in health policy have remained closed or have been opened up to new influences. The analysis suggests that consultation within the health department is more pluralistic than is usually appreciated. Also, while the closed, elitist mode of consultation with external interests has been eroded marginally, it remains more or less intact. Nevertheless, the ability of powerful medical interests to get their own way to the exclusion of other interests depends on the resources and sanctions available to other groups and on the particular policy issue. It can no longer just be assumed.     

Governance,federalism and organizing institutions to manage complex problems

In managing complex policy problems in the federal system, state and local governments are organized into different arrangements for translating policy goals into policy outcomes. Air quality management is used as a test case to understand these variations and their impact on policy outcomes. With data from Clean Air Act implementation plans and a survey of state and local air quality managers, five separate institutional designs are identified: (1) central agencies; (2) top-down; (3) donor–recipient; (4) regional agencies; and (5) emergent governance. Findings indicate that some arrangements (donor–recipient and emergent governance) result in notably better air quality than others (central agencies, top-down). Specifically, when designed to allow bargaining between state and local officials, intergovernmental management is still the most effective approach to complex policy problems; but, in absence of this, conventional federalism arrangements are less effective than public agencies self-organizing around shared policy goals.     

PATIENT CHOICE IN HEALTHCARE IN ENGLAND AND SWEDEN: FROM QUASI‐MARKET AND BACK TO MARKET? A COMPARATIVE ANALYSIS OF FAILURE IN UNLEARNING

This paper compares elements of choice introduced under the market orientated reforms in health systems in the UK and Sweden in the 1990s, and the recent patient choice policy in both countries. It reviews empirical evidence on the impact of choice on users and services under these reforms to examine whether, and how far, these past developments have informed the current choice reforms. The paper asserts that the reappearance of issues and solutions in patient choice policy in the English NHS and in Sweden signifies limited learning from their own past and cross‐national experience, resulting in blurred and mutually exclusive policy agendas. The study argues that this absence of learning happens because of the seeming inability of governments and policy‐makers to unlearn effectively their preconceived ideas and schemas, pointing out the limitations of social learning theory in understanding health policy development.     

THE UNITARY STATE AS A SYSTEM OF CO-GOVERNANCE: THE CASE OF THE NETHERLANDS

The original institutional design of Dutch administration and intergovernmental relations is commonly referred to as the 'decentralized unitary state'. However, the views of traditional administrative theorists have been misrepresented. Hierarchy, uniformity and the separation and delimitation of layers of government are not, as often alleged, the theoretical underpinnings of the Dutch unitary state. Rather, classical theory emphasized interdependence, diversity and the dynamic interaction of relatively independent layers of government. This image suggests that Dutch administration does not need a greater separation of layers of government but better means for regulating conflict. It also suggests that the unitary state comes in several guises and cannot be equated with a monocentric system of government.     

Health care reform content and process:propositions from the states

Health care reform and cost containment have become central campaign and policy issues in the United States. Although focus now centers on federal health care reform policy, state governments have been actively introducing health care reform legislation. Some of the health care reform initiatives on the state level have influenced deliberations on the federal level and President Clinton's health care reform initiatives will spur further state experimentation regardless of legislative success in Congress, In 1992 nearly all 50 states had either legislation introduced, or special task forces assigned that addressed health care reform issues. This exploratory research compares the content and process of health reform in four states that attempted major reform in 1992—Florida, Washington, Michigan, and Wisconsin—and draws propositions for state reform based on comparisons of content and process. The four states chosen represent geographic diversity and a balance between legislation seeking partial change and legislation calling for universal health care reform. The principal reform bills in each state are compared and assessed on the degree to which they address eight reform elements; high tech medicine, administration, tort reform, long-term care, regulation, insurance mandates, small business insurance, and insurance portability. These initiatives are also compared on a series of reform process variables that relate to the political process for adopting reform: degree of health sector support, type of political strategy used, reform champion, degree of cooperation among policy stakeholders, and timing of initiative. Based on these four cases the phased/partial approach seems to have a greater chance for legislative success than immediate universal reform. Florida's partial, consensus-building approach resulted in the only signed bill of the four states. Washington's bill, which also took a partial approach, passed the state senate before ultimate defeat in 1992 and eventual passage in 1993. Neither of the more ambitious universal health care reform packages introduced in Wisconsin or Michigan got out of committee. Although some of the plans were thorough, none adequately addressed the tradeoff between increasing access to care and containing costs. In addition, this study will demonstrate that universal health care legislation, does not necessarily equate to comprehensive health care reform. The propositions derived from this research have implications for future state health care reform efforts, as well as for federal health care reform policy in terms of the substantive content of reform proposals and the political process by which they are advanced.     

THE ROLE OF INTERNATIONAL POLICY TRANSFER WITHIN THE MULTIPLE STREAMS APPROACH: THE CASE OF SMART ELECTRICITY METERING IN AUSTRALIA

This article draws on Kingdon's Multiple Streams Approach (MSA) to consider international, not just domestic, flows of policy. It is argued that using the MSA in conjunction with international policy transfer and mobility theories allows for a fuller explanation of the development of smart electricity metering policy in Australia. The MSA is based originally on empirical research within a single country – the USA – in the late 1970s, and all three of the ‘streams’ identified as important to policy change – problems, politics and policy – are conceptualized as domestic. While recent scholarship has broadened the application of the MSA beyond nation state boundaries, it is argued that there is scope to further develop such ideas. In particular, the notion of policy mobility is introduced to capture issues about the globalization of policy, the role of non‐state actors and the material substance of policy.     

IMPLEMENTING WELFARE REFORM IN MICHIGAN: THE ROLE OF STREET-LEVEL BUREAUCRATS[1]

ABSTRACT

This study examines the implementation of welfare reform policies enacted by the state of Michigan. In particular, it focuses on how welfare policy is altered as it devolves from state policy makers to street-level bureaucrats in three local welfare agencies in Michigan. The analysis reveals that street-level bureaucrats in local welfare offices are in a position to interpret broadly stated goals handed down from officials, and, in some cases, to manage and greatly influence the delivery of services when messages are mixed. The study also suggests that the actual policies or services delivered by front-line workers in welfare offices do not completely correspond with the policy directives issued by state officials.     

The health care state in the information age

The computerization of the medical record has important implications for the governance of health care, and the importance of health care means that changes wrought there are indicative of changes in government as a whole. This paper draws on work in public policy, medical sociology and studies of science and technology, as well as on cross–national empirical research in Britain and France. It describes the recent development of information policy in health care as an exercise in state–building, realized specifically in the governance of the health professions. The paper concludes with a discussion of what is both new and not so new in the form and extent of state power which emerges.     

DECENTRALIZING HEALTH SERVICES IN THE UK: A NEW CONCEPTUAL FRAMEWORK

Decentralization is a central plank of current government health policy. However, it is possible to discern both centralist and decentralist movements in the UK. This paper examines existing frameworks of decentralization in relation to identifying whether policy is decentralist or not and identifies a number of problems that limit their value. Key problems relate to the way decentralization is conceptualized and defined. Existing frameworks are also highly contextualized and are therefore of limited value when applied in different contexts. The paper then presents a new framework which, it is argued, provides a more useful way of examining centralization and decentralization by providing a way of categorizing policies and actions and avoids the problems of being contextually constrained. The paper ends with a discussion of how the framework can be applied in a health context and shows how this framework helps avoid the problems found in previous discussions of decentralization.     

The influence of institutions and culture on health policies: different approaches to integrated care in England and The Netherlands

The concept of integrated care has assumed growing importance on the policy agendas both in England and The Netherlands and elsewhere. It is characterized as health and health care-related social care needed by patients with multi-faceted needs. This article compares policy approaches to integrated care in England and The Netherlands. Differing political strategies and conditions for integrated care correspond to the dissimilarities in the institutional structure and culture of their health care systems. Health care systems are understood as specific national and historical configurations. We review the last decade's relevant policy processes, using the concepts of hierarchy, market and network. The state health care system in England relies mainly on hierarchical steering, thus creating tight network structures for integrated care on the local level. The Netherlands, with its health care system in a public-private mix, has set incentives for voluntary, loosely coupled and partly market-driven cooperation on the local level. Implications for success or failure are mixed in both configurations. Policy recommendations have to be tailored to each systems' characteristics.     

BETTER REGULATION IN EUROPE: BETWEEN PUBLIC MANAGEMENT AND REGULATORY REFORM

Can the European regulatory state be managed? The European Union (EU) and its member states have looked at better regulation as a possible answer to this difficult question. This emerging public policy presents challenges to scholars of public management and administrative reforms, but also opportunities. In this conceptual article, we start from the problems created by the value‐laden discourse used by policy‐makers in this area, and provide a definition and a framework that are suitable for empirical/explanatory research. We then show how public administration scholars could usefully bring better regulation into their research agendas. To be more specific, we situate better regulation in the context of the academic debates on the New Public Management, the political control of bureaucracies, evidence‐based policy, and the regulatory state in Europe.     

THE DYNAMICS OF PROFESSIONS AND DEVELOPMENT OF NEW ROLES IN PUBLIC SERVICES ORGANIZATIONS: THE CASE OF MODERN MATRONS IN THE ENGLISH NHS

This study contributes to research examining how professional autonomy and hierarchy impacts upon the implementation of policy designed to improve the quality of public services delivery through the introduction of new managerial roles. It is based on an empirical examination of a new role for nurses – modern matrons – who are expected by policy-makers to drive organizational change aimed at tackling health care acquired infections (HCAI) in the National Health Service (NHS) within England. First, we show that the changing role of nurses associated with their ongoing professionalization limits the influence of modern matrons over their own ranks in tackling HCAI. Second, the influence of modern matrons over doctors is limited. Third, government policy itself appears inconsistent in its support for the role of modern matrons. The attempts of modern matrons to tackle HCAI appear more effective where infection control activity is situated in professional practice and where modern matrons integrate aspirations for improved infection control within mainstream audit mechanisms in a health care organization.     

State change in Chile, 1973–1988

All of the Southern Cone military regimes of the 1970s articulated a commitment to a neoconservative program of state change. Nowhere, however, was the commitment translated into policy with greater zeal, speed, and consistency than in Chile. What differed in Chile was less a lack of resistance to neoconservatism than the capacity of the economic team to ignore or override that resistance due to the extreme concentration of political power achieved by General Augusto Pinochet. The Chilean experience consequently underlines the importance of institutional arrangements for understanding variations in policy outcomes. Karen L. Remmer is a professor of political science at the University of New Mexico and associate editor of theLatin American Research Review. Her research interests revolve around the interface between politics and economics in Latin America with special reference to the policy impact of regime change.     

MOTIVES AND BEHAVIOUR IN DISTRICT HEALTH AUTHORITIES

With the advent of general managers in District Health Authorities, many members fear they will become the dignified element of the health service constitution, if this has not happened already. If the influence of members is to be retained (or regained) a better understanding of the causes of variations in the influence and effectiveness of members is important. These issues are examined from the perspective of the motives and behaviour of members themselves. Based on research carried out in six health authorities in 1984, a typology is developed which is shown to be useful in predicting the kind of members most likely to achieve individual influence within a DHA, and in diagnosing some of the reasons for differences in corporate influence between DHAs.