TACKLING HEALTH INEQUALITIES IN POST‐DEVOLUTION BRITAIN: DO TARGETS MATTER?

Since devolution in 1998, many aspects of public policy in Great Britain have diverged between England, Scotland and Wales, including how targets and performance assessment are used in the National Health Service and local government. Health inequality is an example where all three countries have recognized a need to act but approaches to performance assessment differ. Based on interviews with senior managers, the complexity of health inequality as an object of local intervention is explored and compared. Despite contrasting approaches to targets, local discourses in all three countries had significant similarities. Health inequality had to compete against a preoccupation with improving access to acute services generally and balancing budgets over the short term. There was a bias in the interventions described towards targeting health behaviours, but with limited use of evidence about efficacy, and indications that measuring progress with reducing health inequalities was starting to lead to an emphasis on ‘quick wins' from pharmacological interventions.     

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.     

HIERARCHICAL MANAGEMENT MONITORING: A Regional Data Collection System in Delinquency

We describe a systematic way of collecting and organizing information on juvenile delinquency. Monthly data are collected from agencies such as police, courts, and corrections, by county and city. These data are aggregated into figures for different levels of administrative responsibility (such as counties, districts, areas, states, and region as a whole). Trends in monthly values are automatically detected, and sudden changes in rates are signaled. Agencies at each administrative level receive appropriate feedback of data on rates, trends, and signals.     

GENERAL MANAGEMENT IN THE NHS: THE INITIAL IMPACT 1983–88

The Griffiths report of 1983 resulted in radical changes (to which the label 'general management' has been applied) to the formalities of organization and management in the national health service. We report the findings of a major study (involving more than 300 interviews) of the impact of these changes up to 1988. Although general management has been widely accepted in the service, and seems to have resulted in some improvements to management processes, there has been no substantial change in organizational culture. We conclude that the impact of the Griffiths model of management has been limited in comparison with the continued influence of medical autonomy and financial limitations.