THE POLITICS AND MANAGEMENT OF HUNG AUTHORITIES

Hung local authorities have grown in numbers in recent years. This paper analyses the experience of those authorities. First it reviews the growing body of literature and argues that it has largely been concerned with particular authorities. The authors then proposed a research-based classification of hung authorities, before examining both the nature of political behaviour and changes in management. Finally, the paper identifies factors leading to stability and instability in hung authorities and the characteristics of both situations.     

INTRA-ORGANIZATIONAL POLITICS IN LOCAL AUTHORITIES: TOWARDS A NEW APPROACH

Much of the recent literature on local government has emphasized the impact of non-local factors on local authority decision-making. This article argues that the administrative processes, power structures and conflicts of interest inside local authorities can often affect policy processes by mediating external influences and providing an internal dynamic of their own. We suggest that most of the current literature concentrates too narrowly on officer-councillor relationships and invariably emphasizes the total dominance of an officer-councillor elite. Our new approach identifies six possible arenas of policy influence within local authorities (of which the officer-councillor elite is just one) and emphasizes the dynamics of intra-organizational politics inside local authorities.     

IMPLEMENTING CHANGE IN HEALTH SYSTEMS: MARKET REFORMS IN HEALTH SYSTEMS IN THE UNITED KINGDOM,SWEDEN AND THE NETHERLANDS

IMPLEMENTING CHANGE IN HEALTH SYSTEMS: MARKET REFORMS IN HEALTH SYSTEMS IN THE UNITED KINGDOM, SWEDEN AND THE NETHERLANDS
Michael I. Harrison
Sage, 2004, 256 pp., £21.99 (pb) ISBN: 0761961763     

CHANGES IN EDUCATION OUTPUTS IN ENGLISH LOCAL AUTHORITIES, 1949–1974

The literature on local outputs is dominated by cross-sectional investigations which suggest that the local socio-economic environment is a critical determinant of local policy. This paper argues that there is insufficient theoretical justification for adopting a cross-sectional methodology. It examines changes in education outputs in 57 English county borough s and 28 English county councils over the period 1949–74 and concludes that long-term trends in output change were little affected by local socio-economic conditions, changes in party control or changes in senior administrative personnel. The results suggest that case study analyses of internal policy-making processes are likely to give more insight into policy determination than current local output analyses.     

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.     

PUBLIC RESPONSIBILITY AND INEQUALITY IN HEALTH INSURANCE COVERAGE: AN EXAMINATION OF AMERICAN STATE HEALTH CARE SYSTEMS

This article examines the effect of the three publicness dimensions on inequality in health insurance coverage across 50 American state‐level health care systems. The analysis validates a Gini‐coefficient measure of Americans' unequal distribution of health insurance coverage across nine income groups and compares public ownership, financing, and control of health care systems across all 50 states from 2002 to 2010. There is a significant and negative relationship between public ownership and inequality in health insurance coverage, although the substantive impact of ownership is relatively small. Both public financing and control substantially reduce inequality in health insurance coverage across income groups. However, both of these must be present in order to be effective at reducing inequality. This article expands our understanding of the link between different institutional arrangements and inequality in health insurance coverage in hybrid health care systems.     

THE THEORY AND PRACTICE OF MANAGED COMPETITION IN THE NATIONAL HEALTH SERVICE

This article presents qualitative and survey evidence on the implementation of managed competition in the NHS. After outlining the economic analysis of quasi-markets made by Le Grand and Bartlett, Part I argues that a framework derived from organization theory is a more fruitful way of analysing and understanding behaviour at local level. Part II describes the experience of implementation in four district health authorities, concentrating on the way key actors conceptualized market relations and the way market imperfections were addressed. Part III discusses the main reasons why implementation took the form it did and the factors shaping similar or dissimilar responses.     

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.     

TRANSFORMING PUBLIC SERVICES: CONTRACTING FOR SOCIAL AND HEALTH SERVICES IN THE US

Government contracting with private service organizations has grown rapidly in the United States in the last 25 years. Advocates of contracting hope that it will spur competition among service agencies, lowering costs and improving service quality. In practice, however, contracting departs significantly from this competitive model. Instead, government and private agencies develop long-term relationships which can be considered regimes governed by specific norms and expectations. These regimes profoundly influence the delivery of services and the politics of contracting. This article analyses these regimes in the context of the contested nature of public authority. The article concludes with suggestions for reforming public policy to improve the performance and effectiveness of contracted services.     

FROM PROVIDING TO ENABLING: LOCAL AUTHORITIES AND THE MIXED ECONOMY OF SOCIAL CARE

Government policy seeks to introduce competition into the supply of social care through the separation of purchasing and providing responsibilities. A study of 24 local authority social service departments has explored the initial steps taken to prepare for the new enabling role, including the creation of a mixed economy of care. Very few were seeking to create a market in social care. Most argued that the inherent nature of social care rendered the introduction of service specifications and price mechanisms neither approriate nor feasible. Many authorities interpreted the enabling role in ways significantly different from that of the government. The study raises questions about the extent of local discretion in a context where the range of values and interests of implementing agencies may differ from those of the centre.     

THE CONDITIONS FOR HEALTH AND SOCIAL CARE POLICY: ROUTINES AND INSTITUTIONS IN THE DUTCH CASE OF NEED ASSESSMENT

By focusing on institutions (rules for action) and routines (patterned behaviour) our intention is to contribute to the understanding of government policy and its outcomes in health and social care. We analysed data to show how the relationship between a new idea for a routine and new rules from the government on the one hand, and existing rules and routines in society on the other, as well as the interaction between rule makers and rule takers (i.e. those who are governed by those rules), have an impact on the change or maintenance of routines. The data concern the case of government policy for need assessment (that is, assessment of needs) in The Netherlands. As our discussion will show, even a national government, however, is not able to completely impose its will on other agents in order to change existing routines. The concept of ‘negotiated order’ helps us to understand why. In the case reported here, the Dutch government and the home care agencies had to exercise give and take, the outcome being a suboptimal result for both.     

PROFESSIONAL AUTONOMY AND PASTORAL POWER: THE TRANSFORMATION OF QUALITY REGISTERS IN SWEDISH HEALTH CARE

In the context of the recent transformation of control in Swedish health care, the changing role of quality registers are analysed as a vivid example of how professional groups become involved in new modes of regulating professional work. Based on a critical appraisal of the main currents in the research on NPM, it is argued that understanding ‘the productive side of power’ is an underexploited theme. The main part of the article is devoted to a detailed analysis of how a seemingly insignificant, but in its consequences important, professional practice was transformed from a resource for clinical research, an entirely professional concern, to a tool for hierarchical control. In the concluding sections, a number of important conditions for the successful use of ‘soft power’ in modern societies are identified and discussed.     

PUBLICS,PATIENTS, CITIZENS,CONSUMERS? POWER AND DECISION MAKING IN PRIMARY HEALTH CARE

This article uses theoretical approaches to the discussion of power in order to consider the role of public and patient participation in primary health care organizations in the UK. There is considerable evidence to suggest that, despite major national initiatives to extend participation in health services, the role of participation in decision making remains underdeveloped. The primary purpose of this article is to understand how and why this should be the case. Using findings from qualitative research that explored approaches taken by the dominant professional groups on primary care groups (PCGs) to involving patients and the public, we consider how these approaches reflect the exercise of different forms and levels of power. The explanation combines Lukes’ categorization of three forms of power with Bourdieu’s dynamic conceptualization of the relations of habitus and field. It is argued that the models observed represent different opportunities for the operation of power with implications for the role that participation can play.     

GOVERNING MENTAL HEALTH CARE: HOW POWER IS EXERTED IN AND THROUGH A QUALITY IMPROVEMENT COLLABORATIVE

We investigated the role of power in public governance using a Foucauldian conceptualization of power, i.e., power is produced by a range of techniques as diverse as language and measuring. We draw on an evaluation study of a quality improvement collaborative, in which different mental health care organizations were encouraged to improve their care in a structured way. We analyzed how the different actors involved in the collaborative were governed and came to govern themselves differently. Measurement instruments were an example of a dominant mechanism by which actors at different levels of the collaborative were governed: by accounting for improvements, introducing or strengthening a certain way of thinking about health care clients, and changing how clients thought about and acted upon themselves. We argue that the focus on consequences of governing techniques is fruitful for studying governmentality and leads to new research questions in the context of public policy analyses.     

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.     

THE IMPACT OF PUBLIC SERVICE MOTIVES ON WORK OUTCOMES IN AUSTRALIA: A COMPARATIVE MULTI‐DIMENSIONAL ANALYSIS

There is a general consensus that individuals who are driven to serve the public interest can possess a mix of public service motives for engaging in altruistic actions. This article proposes that when analysed simultaneously, some public service motives may play a more important role than others in influencing work outcomes. The pressing questions are which ones and how? Through a survey of a group of Australian public sector employees, this article explores the relationship between the various dimensions of public service motivation (PSM) and the common work outcomes: organizational commitment, job satisfaction and job motivation. The combinations of PSM dimensions that had a greater impact on these work outcomes are also found to vary with different outcomes.