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.     

PATH DEPENDENCY AND INSTITUTIONAL CHANGE: THE CASE OF INDUSTRIAL EMISSION CONTROL IN SWEDEN

Theory‐independent measures of institutional change can be developed by identifying and tracking changes in institutional reproduction mechanisms. Such measures can then be used to assess the empirical validity of theoretical models of institutional change. This article performs an analysis of reproduction mechanisms in a case study of a Swedish institution for emission control during the period 1960–2000. The analysis reveals the existence of a highly path dependent institutional development, powerful enough to withstand a wide‐ranging institutional reform implemented in the late 1990s. The case study supports a gradualist model over a punctuated equilibrium model of institutional change, but the analysis also demonstrates the need for path dependency theory to pay greater attention to the question of how micro‐level institutional interaction generates aggregate patterns of change and stability.     

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     

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.     

IDENTIFYING CAUSALITY IN PUBLIC INSTITUTIONAL CHANGE: THE ADAPTATION OF THE NATIONAL ASSEMBLY FOR WALES TO THE EUROPEAN UNION

The aim of this article is to identify causes and effects of public institutional change. Analysis is centred on those endogenous, not exogenous, sources of political change that account for the institutional metamorphosis of the Welsh Assembly in its engagement with UK‐EU processes since 1999. The central research question addressed is to explain a qualitative shift in the logic of action of Assembly engagement, resulting in the conduct of a territorially sensitive ‘parliamentary’ EU scrutiny, but within a model of executive devolution. To capture agency and change, and to engage with sociological institutionalist debates, the article develops analytical tools of ‘framing’ and ‘operationalizing’ institutions to study the interplay between informal and formal processes of institution building since devolution. In so doing, we place refined sociological conceptions of institutions at the heart of analyses of political discontinuity and theorization of public institutional change.     

COMPETITION OR MONOPOLY? COMPARING PRIVATIZATION OF LOCAL PUBLIC SERVICES IN THE US AND SPAIN

Differences in national traditions of public intervention, institutional arrangements and public service markets make local public services an area of great diversity. In this paper we undertake a comparative study of how local governments arrange for delivery of water and waste services in the US and Spain. We find levels of privatization are higher in Spain than in the US. We review organizational reform in the two contexts and compare service delivery data using national surveys from each country. We find lower and less stable privatization in the US stems in part from adherence to public choice emphasis on the benefits of market competition over public monopoly. By contrast, Spanish municipalities reflect an industrial organization approach, and create hybrid public/private firms which benefit from both market engagement and economies of scale available under monopoly production. We conclude that managing monopoly may be more important than competition in local service delivery.     

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.     

STRUCTURAL CHANGE IN THE NHS AND GP UTILIZATION IN ENGLAND UNDER NEW LABOUR, 1997–2003

In this article we compare the pattern of service utilization in the period preceding the health‐care reforms introduced by New Labour with service utilization following the refoms. Data from the 1997 and 2003 waves of the British Household Panel Survey are used to estimate a series of utilization functions. These show that GP utilization overall fell, for women more than men and for the sick more than others. The results suggest that GPs responded to the changing context the reforms created but there are different interpretations of that response. They support the contention that GPs devoted greater attention to preventative services post‐reform than had previously been the case. They are also consistent with the contention that GPs responded less directly to the needs of their patients, either because they became more sophisticated in interpreting those needs or conscious of the increased opportunity costs of responding to them.     

NEW GOVERNANCE ARRANGEMENTS AT THE INTERSECTION OF CLIMATE CHANGE AND FOREST POLICY: INSTITUTIONAL,POLITICAL AND REGULATORY DIMENSIONS

This article investigates emerging governance arrangements at the intersection between forest management and climate policy. The authors deploy the symposium's three‐dimensional framework to describe and evaluate developments within two distinct policy sectors (forestry/climate change adaptation and mitigation) at several levels of governance (bi‐national, national, and sub‐national) to explore the nature and operation of the emerging governance arrangements, and assessing and measuring change within these arrangements over time. Drawing on four contemporary case studies from the US and Canada, New Zealand, British Columbia and Alaska, the authors discern little evidence of a generalized, linear trend from ‘government to governance’. Instead, they conclude, across institutional, political and regulatory dimensions of governance, a more variegated and diverse picture emerges. Their analysis also lends support for the Trubek and Trubek (2007) hypothesis that emerging governance arrangements typically interact with extant ones through modalities of rivalry, complementarity and transformation.     

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.     

GOVERNANCE AS POLITY: AN INSTITUTIONAL APPROACH TO THE EVOLUTION OF STATE FUNCTIONS IN IRELAND

State institutions mediate the challenges of globalization for the domestic political community: the concerns of specialists in comparative politics and in public administration are increasingly converging round an interest in the nature and functioning of state institutions. This paper draws on preliminary findings from a time-series database of national-level political institutions in Ireland to track continuity and change in state functions through analysis of state agencies. It also identifies four modes of state action: developmental, regulatory, adjudicatory, and moral advocacy, each of which has a traditional and a modern manifestation. While the first two modes are familiar in comparative context, the latter two are likely to merit further analysis cross-nationally.     

CHANGE IN THE CIVIL SERVICE: RETROSPECT AND PROSPECTS

The type of civil service modelled on the principles of the Victorian reformers survived virtually unscathed into the post-1945 era of the welfare state and managed economy. Criticism of its qualities and performance resulted in a programme of changes associated principally with the Fulton Report (1968). This initial reform phase identified a shift to more active management of personnel, resources and policies as the primary need, but its practical effects were muted by optimistic assumptions relating to the rate of economic growth and the benefits to be derived from continued extension of governmental responsibilities. Since 1979 the context of civil service reform has changed, imposing much stronger pressure in favour of a managerialist view of civil service functions, of a career in the civil service, and of the ethos of the profession. Despite ambiguities of purpose and constraints within the political system the course of change is likely to continue in the direction, pointing towards a civil service substantially different at the end of the century from that which has been familiar in British thinking about the character and status of officials.     

LEADERSHIP IN PUBLIC SERVICES NETWORKS: ANTECEDENTS,PROCESS AND OUTCOME

In this article, the authors examine the implementation of policy aimed to promote the role of organizational networks and distributed leadership in the establishment and consolidation of public service reform. In theory, leadership and networks should complement each other, with the less hierarchical logic of the network allowing leadership of change, distributed among network members, rather than led from a single organizational apex, to flourish. In practice, as a consequence of inherent bureaucracy, power differentials between network participants, and a strong centralized performance management policy regime, a relatively parsimonious form of distributed leadership is enacted, with the networks tending towards ‘managed partnerships’.