eHEALTH IN THE PUBLIC SECTOR: AN EMPIRICAL ANALYSIS OF THE ACCEPTANCE OF GERMANY'S ELECTRONIC HEALTH CARD

Given the increasing importance of eHealth as an integral part of eGovernment, this contribution concentrates on the issue of acceptance regarding the introduction of the German electronic health card (eHC). A brief introduction highlights the relevance of the subject and the differing acceptance rates of patients and service providers, i.e. physicians. Based on both the technology acceptance model and the relevant literature, important factors influencing the attitude towards and the potential use of the eHC are conceptualized and integrated in a research model. The empirical examination was conducted throughout Germany through an online survey of physicians. Overall, 502 responses were collected and included in the analysis, which was carried out with structural equation modelling using EQS. The empirical results show that the relevant determinants of the acceptance of the eHC in Germany, such as efficiency and usability of the system and the cost–benefit ratio, were properly identified.     

WHAT’S MEASURED IS WHAT MATTERS: TARGETS AND GAMING IN THE ENGLISH PUBLIC HEALTH CARE SYSTEM

In the 2000s, governments in the UK, particularly in England, developed a system of governance of public services that combined targets with an element of terror. This has obvious parallels with the Soviet regime, which was initially successful but then collapsed. Assumptions underlying governance by targets represent synecdoche (taking a part to stand for a whole); and that problems of measurement and gaming do not matter. We examine the robustness of the regime of targets and terror to these assumptions using evidence from the English public health service on reported successes, problems of measurement, and gaming. Given this account, we consider the adequacy of current audit arrangements and ways of developing governance by targets in order to counter the problems we have identified.     

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     

EQUAL OPPORTUNITIES POLICIES AND RACIAL INEQUALITY: THE ROLE OF PUBLIC POLICY

This article examines the seeming contradiction between the publicly stated objective of successive governments to promote greater equality of opportunity for racial minorities and the limited impact of successive policies and programmes on processes of racial discrimination and exclusion in British society. The article begins by outlining the different conceptual approaches used to analyse the development of public policies on racial inequality. It then analyses the main aspects of national policy change in this area over the past two decades, and more recent initiatives which have sought to use local government as a vehicle for promoting racial equality. This analysis offers a critical review of the achievements and limitations of both past and present policies. The concluding section takes up the question of the prospects of change in the future.     

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.     

PUBLIC EXPENDITURE AND POLICY IMPLEMENTATION: THE CASE OF COMMUNITY CARE

This article explores the contention that the conventions of public expenditure accounting conceal, rather than reveal, the real nature and implications of resource trends. A benchmark — a constant level of service output — is established as a basis for examining the relationship between trends in expenditure inputs and service outputs. Changes in unit costs are identified as the major source of deviation between expenditure and output trends. The impact of resource constraint on policy and policy-implementation is then examined in relation to one, essentially stable, area of policy in the personal social services: community care.
The meaning of the term'policy' is far from straightforward and community care is best understood as the interaction of relatively independent streams of policy, towards service outputs and resource inputs, extant in both central and local government. Mechanisms by which policy streams could be reconciled are of particular interest and an innovative example — joint finance — is examined in some detail.     

MANAGING INFORMATION SYSTEMS IN UK PUBLIC ADMINISTRATION: ISSUES AND PROSPECTS

The record on the development and use of information-based technologies in UK public administration is reviewed and distinctive risks identified. Risk levels associated with computerization may be increasing rather than abating as a result of both the content of New Public Management initiatives, and also how they are being introduced and applied. This article considers ways forward from the point of view of improving how informatization can proceed, and also how markets can be used to provide information-based services for public administration.     

THE SHIFTING STATE: PUBLIC ADMINISTRATION IN A TIME OF CHANGE

This is the keynote address given by the Right Hon The Lord Scarman, OBE, Lord of Appeal in Ordinary and the RIPA's President, at the Institute's Conference on'The Shifting State: Rules, Roles and Boundaries in the 198s', held at the University of Aston, 14–15 September 1984.     

THE PARADOX OF POLICY DIVERSITY IN A UNITARY STATE: COMMUNITY CARE IN BRITAIN

Studies of policy-making and management in health and related fields have generally been confined to England even when professing to embrace Britain or the United Kingdom. The assumption of a unitary state in which the policy lead is given by Westminster/Whitehall is shown to be grossly misleading in the case of community care policy. Considerable variations exist not only in policy means but also in policy ends. The paper demonstrates the limitations of studying health and personal social services adopting a unitary state perspective. It argues for more intra-Britain comparative work aimed at evaluating the costs and benefits of service variations in different policy fields.     

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.     

THE ENTERPRISE FORMULA,NEW PUBLIC MANAGEMENT AND THE ITALIAN HEALTH CARE SYSTEM: REMEDY OR CONTAGION?

Health care services represent an extraordinary experimental ground for introducing wider political and institutional transformations of the state. The adoption of entrepreneurialism into European health care systems has strengthened technocratic decision making over traditional mechanisms of political control. In Italy, in the midst of a severe legitimacy crisis affecting the administrative and political systems at the beginning of the 1990s, New Public Management ideas seemed ‘the’ remedy against the pathological politicization of distributive politics. Much hope has been placed since in a new and ascending group of general managers, entrusted with the ambitious mission of running health care services more efficiently and with the unenviable expectation of resuscitating public trust in welfare institutions. By analysing the 1992 Amato government’s landmark health care reform in its substantive changes, this paper explores the last decade’s main reform trajectories of Italian health care reforms that irreversibly transformed its institutional arrangements and organizational structure, namely the enterprise formula and the regionalization of the health care sector. The paper suggests that the political turmoil of 1992–94 served as catalyst for radical policy change and argues that the single most important explanation for the enactment of New Public Management‐type reforms rests in a new executive reinterpretation of its legislative prerogatives and function.     

PUBLIC BUDGETING AND ECONOMIC DEVELOPMENT: EVOLUTION AND PRACTICE OF AN IDEA

One of the major dimensions of public budgeting relates to the generation of growth, employment, and more favorable income redistribution in the economy. This dimension had come to acquire a good deal of importance during the last seventy years. The use of public budgeting for purposes of promoting economic growth, employment, income distribution, has so far been considered as a part of development economics in general, and more specifically, as a part of economic planning. Indeed, such use has been so extensive that it is difficult to consider budgeting for economic development without a consideration of organized economic planning and associated formulation of medium term and annual plans. Planning itself has gone through several vicissitudes during these decades. As an extension, budgeting too has gone through several phases. By 1985, nearly 300 plans were formulated by developing countries. During the same period, the approaches in industrial countries of the west incorporated some elements of organized planning into their budgetary systems. By early 1990s, however, there was a noticeable sense of fatigue with planning. The state which was seen thus far as a solution to market failure, came to be viewed as a major problem in itself, standing between the legitimate aspirations of the community and their realization. Countries, particularly those belonging to the Soviet block, moved away from planning for economic development and came to adopt market friendly policies. In the process, several countries have abandoned formulation of economic development plans. In these countries, there has been a revival, and, therefore, strengthening of public budget as the one and only instrument of economic development conceived, sponsored, funded, and to a significant extent, implemented by the government. Plans, which at one stage had generated the illusion of permanence, proved after all, to be as transient as many other things in the world.     

PROFESSIONAL POWER PLAY: ORGANIZING MANAGEMENT IN HEALTH CARE

Because of the managerialization of health care and the rise of health care managers, professionals and managers increasingly ‘clash’. To reduce clashes, managerial and professional domains have not only been (re)connected; they have also been restructured. Managers, in particular, have started to make sense of their own ‘professionalism’. Health care managers are professionalizing in order to cope with reform consequences. They have established professional associations, which establish educational programmes, journals, and codes of conduct, in order to define and standardize managerial work. By tracing the evolution of a new profession of Dutch health care executives, and by studying its educational underpinnings, this article will analyse whether the professionalization of managers homogenizes occupational definitions and standards. It will show that managerial education masks ideological struggles over the substance of ‘good’ health care management. Different ‘schools’ have arisen, producing heterogeneity in executive circles.     

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.     

THE DIFFICULT TRANSFORMATION OF STATE AND PUBLIC ADMINISTRATION IN PORTUGAL. EUROPEANIZATION AND THE PERSISTENCE OF NEO‐PATRIMONIALISM

Portugal has been characterized by a late discontinuous democratization process. This contribution discusses the case of state and public administration reform in Portugal by using approaches from democratization, modernization and Europeanization theories. In order to understand the Portuguese case, the concept of ‘neo‐patrimonialism’ is used. We characterize Portuguese public administration as still having ‘neo‐patrimonial’ features, and therefore is still in transition from old closed‐minded practices such as particularistic decision making or clientelistic relationships to new open‐minded ones. The ‘new’ governance agenda combines new public management instruments and a growing flexibilization of public administration towards networks with non‐statal actors and has certainly led to some improvement in the quality of the services associated with public administration. Although is still too early to assess, top‐down and horizontal Europeanization processes, particularly since the late 1990s, may have contributed to a more reflexive approach in moving towards a more endogenous strategic vision based on the needs of the Portuguese state and public administration.     

FISCAL FEDERALISM, PROFESSIONALISM AND THE TRANSFORMATION OF AMERICAN STATE GOVERNMENT

A combination of political and economic forces have helped to return the states to the centre of the political stage. Whether measured by objective indicators (employment, share of government expenditure, elasticity of state revenues) or political institutional changes (the rise of career governors, the increasing influence of the intergovernmental lobby and the spread of state responsibilities), the states have become increasingly important in the formulation and implementation of American domestic policies. However, these changes have by no means reduced the level of intergovernmental conflict. On the contrary, cuts in federal expenditure, the introduction of block grants and public opposition to increases in state and local taxation are likely to intensify debate on distributional questions at the state level.     

PUBLIC LAWYERS AND PUBLIC ADMINISTRATORS: PROSPECTS FOR AN ALLIANCE?

There is in Britain a longstanding gulf between the study and practice of public administration on the one hand, and the study and practice of public law on the other. This state of affairs contrasts sharply with the situation in many other countries of Western Europe, where public administration is underpinned by well-developed systems of administrative law. Recent procedural and substantive developments in the field of judicial review of administrative action, together with intensification of debate about constitutional issues, such as the desirability of enacting a new Bill of Rights, have increased the urgency of improving communications and collaboration between these two cognate areas of activity. The burgeoning literature of public law, and the law reports of cases in this subject-area, constitute a potentially invaluable quarry of source-material for students of British public administration.