RENEWING POLICY TO SUPPORT EVIDENCE‐BASED HEALTH CARE

Health systems internationally have developed policies to support evidence‐based health care (EBHC) for over a decade. As this article shows, the time is ripe to review current policy frameworks in an evidence‐based manner. We summarize key themes deriving from qualitative research on the UK EBHC implementation and draw out implications for policy renewal. Our diagnosis is different from current UK NHS (National Health Service) policy since we stress local capacity building rather than top‐down frameworks, standardized tools and guidelines. As other jurisdictions demonstrate alternative EBHC policy frameworks, more international comparison and mutual learning is needed.     

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 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.     

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.     

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.     

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.     

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.     

DECIDING HOW TO DECIDE: THE CASE OF HEALTH CARE RATIONING

One of the challenges awaiting health care systems around the world is the containment of expenses in the face of exploding costs for new drugs and treatments. In most countries, the allocation of health care has not been politicized so far and the problem is still treated as a purely regulative one. However, there is increasing interest in the procedures used for priority-setting. The paper argues that while normative standards for their evaluation are desirable, more attention should be paid to institutional factors and their effects. I identify two demands on decision-making—discursiveness and coordinativeness—from which I derive four ideal-typical procedures. By way of international comparison, corresponding empirical cases are analysed. I conclude with considerations on whether efficient and publicly accepted decisions over the allocation of health care are possible and, if yes, by means of what type of procedures and in what forum(s) they can be taken.     

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.