Decentring Health Policy

Learning from British Experiences in Healthcare Governance

Mark Bevir, Justin Waring, Mark Bevir, Justin Waring

• Publisher: Taylor & Francis
• Year: 2017
• Print ISBN: 9781138232990
• eBook ISBN: 9781315310794
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Politics
• Index: Politics & International Relations

Taking a 'decentred' approach to the analysis of health policy means being attentive to the historical contingencies and circumstances within which reforms are located, the influence of dominant or elite narratives in the shaping of policy, the local traditions and customary practices through which policies are mobilised, and the way local actors contest, negotiate and co-construct policy.

This book offers a unique analysis of the changing landscape of healthcare reform in Britain, as an example of decentralized reforms across the developed world. The collection is framed by the recognition that healthcare reform has resulted in variegated and decentralized forms of governance. The chapters look at distinct aspects of reform within the British NHS to bring to light the influence of local histories, traditions, coalitions, and values, in the remaking of a national healthcare system. Each chapter focuses on a different aspects of reform, and in others developing cross-national and comparative analysis. However, each offers a unique contribution and analysis of contemporary theories of healthcare governance.

This book will be of key interest to scholars, students and practitioners in healthcare, health and social policy, political science, and public management and governance.

1 Decentring health policy

Traditions, narratives, dilemmas

Mark Bevir and Justin Waring

The changing health policy landscape

Healthcare systems across the developed world appear to be in a near constant state of change. Policy makers and service leaders seem locked in cycles of introducing structural reform, regulatory change or organisational innovations, in their continuing attempts to remedy the persistent dilemmas faced by contemporary healthcare services, including those created by previous reforms (Smith, Walshe, & Hunter, 2001). In the current period, these problems are often framed as the ‘triple challenge’ of improving patient experience and care quality, improving population healthcare, and reducing per capita costs (Berwick, Nolan, & Whittington, 2008). Arguably, this is a new framing for widespread and longstanding political and economic concerns about the spiralling costs of providing healthcare to an aging population with long-term conditions and, for some care systems, where significant sections of the population are under-served. Since the early 1970s, questions of cost containment, patient access and standards of care have featured consistently in policy priorities (Alford, 1977). The reform imperatives created by these apparent dilemmas have called into question the established models of twentieth century health system governance, e.g. the Beveridge or Bismarck models (Greer, Wismar, & Figueras, 2016), and compelled service leaders to look for evermore innovative solutions to solve the dilemmas of service organisation and delivery.

It might be argued that some international consensus has emerged for how elements of these challenges might be resolved. With the funding and financing of care, for instance, there seems to be some shared assumptions that state subsidies are necessary to ensure public access, and that markets ensure efficient, transparent and responsive resource allocation (Ham, 2009). Similarly, the governance of healthcare professional work has seen the widespread adoption of evidence-based medicine, and other quality improvement methods, as a basis for standardising and promoting the quality of care (Berwick, 2003; Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996).

Although these challenges, and solutions, appear common to most, if not all, developed healthcare systems, the policies and strategies proposed typically reflect local (national) historical circumstances. Local circumstances continue to shape health system reform through presenting context-specific challenges or by refracting global narratives into local instances of change and contestation. A prominent feature of contemporary healthcare reform is the way new policies are commonly developed as a corrective to the problems created by previous cycles of reform. As suggested by Greer et al., (2016, p. 3) ‘the world is cluttered with good health policies gone wrong’. As such, health system reform seems as much concerned with undoing or mollifying past reforms, as much as with addressing the underlying challenges faced by healthcare systems. In the US, for example, the signature health reform of the Obama administration – the Patient Protection and Affordable Care Act – has been systematically unpicked through both Congress and the executive powers of President Trump. The cycles of reform often reflect distinct political ideologies about how healthcare can be modernised to address the underlying pressures, leading to local trajectories of health system reform.

The contemporary transitions in healthcare governance bring to light broader social science narratives that have been influential across public policy and governance (Greer et al., 2016). The first is a shift from, what might be termed, the traditions of public administration and the organisation of care through ‘professional bureaucracy’ (Mintzberg, 1979), to the managerialisation and marketisation of healthcare services. These reforms are often described under the narrative of ‘New Public Management’, and illustrate the influence of particular theories such as neo-institutional economics, public choice theory and principle-agent theory; together with a swathe of managerial fashions (Hood, 1991; Ferlie, Ashburner, Fitzgerald, & Pettigrew, 1996; Osborne & Gaebler, 1992). The second is a shift towards was a more progressive, networked or collaborative mode of governance (Newman, 2001; Rhodes, 1997). Informed by different economic, sociological and managerial theories, the narrative of ‘network governance’ is often presented as an alternative to both bureaucratic planning and market competition, with social relationships coordinated and governed on the basis of shared interests, inter-dependence, negotiated settlements, and mutual advantage. Networks offer policy-makers a more inclusive and innovative mode of addressing the complex or wicked social problems facing society through joining together disparate specialists and stakeholders (Ferlie, Fitzgerald, McGivern, Dopson, & Bennett, 2013). The changing landscape of public governance has led to a new grand narrative of ‘de-centralised governance’ to describe a mode of governance where the State has a diminished role in hands-on service organisation, and instead a multitude of policy actors and stakeholders interact through polycentric networks to coordinate and organise services (Newman, 2001; Rhodes, 1997).

The British National Health Service (NHS) – the focus of this collection – exemplifies the changing governance landscape. The NHS was founded in 1948 and reflected the type of civil service and administrative ethos of the time, whilst according considerable authority to the medical profession at the levels of policy-making, resource allocation and clinical work (Freidson, 1970; Klein, 1989). However, its earlier formation and subsequent reforms reveal a highly contested and contingent political history, being introduced in the wake of protracted and contested negotiations between the medical profession and government, in the midst of post-war reconstruction, and under the influence of a pragmatic, but also socialist figurehead – Aneurin Bevan (Klein, 1989). As discussed by Speed in this collection, the service was founded on the principle of universalism, with care provided on the basis of need, not ability to pay. Today, the service remains largely funded through central taxation, with care ‘free at the point of need’ and, for the first period of its history, resources and policies were planned and cascaded through the bureaucratic hierarchies of regional and district authorities (Ham, 2009).

By the early 1980s, the British political environment had changed considerably with a perceived crisis in the post-war welfare consensus, and the election of Margaret Thatcher and her explicit neoliberal reform agenda concerned with reducing the scale and burden of the bureaucratic State and liberating market forces (Gamble, 1992). Despite receiving relatively positive support from the earlier Merrison Report (Merrison, 1979), the NHS became and would remain a target for reform. Over the next 30 years, the NHS would undergo some of the most profound reforms, each influenced by the particular political ideologies, social science orthodoxies, and management fashions of the day. Illustrating the rise of NPM, the 1980s and 1990s saw the bureaucratic hierarchies of the NHS regions, districts and areas systematically dismantled and disaggregated into discrete, local purchasing (e.g. commissioning groups) and provider units (e.g. quasi-autonomous hospitals) operating within a marketised environment (Ham, 2009).

Under the guidance of supermarket chairman Sir Roy Griffiths, the mid-1980s saw the introduction of General Management, with the expectation that local ‘service’ managers would be accountable for delivering national policy objectives and delivering performance improvements (Waring, 2013). For many commentators, general management represented a countervailing power to the prevailing dominance of the healthcare professions in the organisation of care services (Harrison & Ahmad, 2000; Strong & Robinson, 1990).

The 1990s saw the introduction of internal markets, with groups of GPs encouraged to become the ‘purchasers’ of patient care from a marketplace of quasi-autonomous hospitals (Le Grand & Robinson, 1994). The internal market reforms extended the influence of managerial and accounting practices in the organisation of care, representing a fundamental shift from central or regional planning. For policy-makers, the internal market would break the gridlock and disincentives of NHS bureaucracy, where competition would delivery greater efficiency and responsiveness.

Yet, by the mid-1990s the realisation of these goals seemed questionable, and new policy narratives were taking hold in British public policy, which became a dominant feature of the New Labour period. Although the fundamentals of the NHS internal market were not be replaced, and remain to this day, the late 1990s saw a shift towards more progressive or networked forms of health policy. In broad terms, networks were seen as mollifying the ‘hard edges’ of marketisation, especially the risk of service fragmentation, and restoring the link with citizens rather than customers (Newman, 2001). Across almost all areas of health policy there has been an expectation that relevant stakeholders should inform decision-making, as exemplified by the growth of Public and Patient Involvement; a theme examined by Martin and Carter, and by Stewart in this collection. Networks were also presented as a platform for service innovation and improvement, especially for tackling the ‘wicked’ problems faced by the NHS (Ferlie et al., 2013). From the creation of new clinical evidence through to the delivery of frontline service, networks and collaborations are still assumed to facilitate resource sharing and foster more inclusive decision-making. Networks and networking feature across a number of the chapters presented in this collection as a dominant mode of service organisation, but where the everyday reality of ‘networked’ care often seems in tension with the historical fabric of service delivery and professional work.

The recent history of the British NHS reveals a further example of de-centring through the devolution of political responsibility for healthcare to the individual nation-states that comprise the United Kingdom. As such, England, Wales, Scotland and Northern Ireland appear to be pursuing different health policy trajectories. A number of chapters in this collection explore the impact of devolution on, what was, the British NHS, showing aspects of both continuity and change. Whilst England has pursued a more explicit market approach with overlaid networks, Wales and Scotland have returned to more central planning with instances of networking. What emerges from the experiences of devolution is the continuing connections between national healthcare systems, especially the influence of the English model, which at times provides a template for management change, whilst at others a justification to maintain more traditional or local policy pathways. As explored in this collection by Greer, Ralston and Smith, and Stewart, devolution does not always suggest a clean break from, nor indeed continuity with, the past. The devolution of service planning and governance looks set to continue at the regional level within England, with Greater Manchester taking greater responsibility for the health and social care, and with English health regions required to devise local Sustainability and Transformation Plans to shape the future of regional health planning (Department of Health, 2014).

The British NHS therefore offers something of an exemplary case, even unique ‘natural experiment’, for the decentralisation and devolution of health policy. It represents a particular form or modality of policy-making, service organisation and configuration of professional work that we characterise as ‘decentralised governance’.

In its broadest sense, the narrative of ‘decentralised governance’ has close parallels with the idea of the ‘hollowed-out’ State, suggesting that healthcare services, like other areas of public policy, are no longer ‘centred’ or governed through the machinery of a central State. Rather, services are organised through a diverse array of decentralised and disaggregated agencies, some of which are engaging in more competitive, and others in more collaborative relationships. Although it is attractive to distinguish between particular reform periods – bureaucracy, markets, networks – the broader narrative of ‘decentralised governance’ creates a space for these variegated and distinct patterns of reform to be seen from a broader perspective, and as illustrating a broader trend. Further still, it is important to caution against an overly deterministic understanding of the governance modalities, and to appreciate that these particular governance arrangements overlap, interact and compete, resulting in a more dynamic and messy form of decentralised governance. Questioning the idea of a ‘hollowed-out’ state, Skelcher (2000) highlights the continued relevance of the central State in creating and directing decentralised policy networks. Exworthy, Powell, and Mohan (1999) similarly argue that the different modes of healthcare governance co-exist in partial forms, involving quasi-bureaucracy, quasi-markets and quasi-networks. Analysis of the more recent English NHS reforms reveals the influence of pre-existing networked arrangements as well as the resurgence of more market systems cutting across both local and national domains (Exworthy & Mannion, 2016). As suggested by Jones in this collection, what emerges is a form of ‘sedimented’ governance, where patterns of governance are layered above, and often in reaction to, preceding patterns. As such, the British NHS reflects a plurality and, at times, confused array of decentralised governance arrangements.

The contingent and contested nature of these governance institutions calls into question the very idea of seeking to define or characterise these modalities in the form of enduring institutions or structural arrangements. Although the idea of decentralised governance might reflect the broad trend, it is necessary to look beyond such characterisation to bring to light the diverse meanings and practices that are involved in healthcare governance, and to locate these within the context of particular histories and traditions, and the influence of prevailing narratives or orthodoxies (Bevir, 2013). What we are suggesting therefore is a shift from describing ‘decentralised’ healthcare governance to developing a ‘decentred’ theory of healthcare governance. This decentred approach offers a form of inquiry that looks beyond the structures, institutions and grand narratives of governance, to examine instead the historical and context-specific meanings and assumptions that inform governance practices.

Decentred theory

Modernist social science typically seeks mid-level, or even general, theories by which to explain the particulars of social life, including the adoption, operation, and effects of a policy. They prefer explanations that are formal, as opposed to historical, precisely because they conceive that explanations must be synchronic accounts of patterns that persist across multiple cases from which to build a mid-level or general theory (Brady & Collier, 2004; King, Keohane, & Verba, 1994). Decentred theory contrasts sharply with this modernist approach. Decentred theory is overtly historicist in its emphasis on agency, contingency, and context (Bevir, 2003a; Bevir, 2013). It rejects the hubris of mid-level or comprehensive explanations that claim to unpack the essential properties and necessary logics of social and political life. So, for example, it suggests that neither the intrinsic rationality of markets, nor the path dependency of institutions, properly determines whether policies are adopted, how they coalesce into patterns of governance, or what effects they have. Rather, decentred theory conceives of public policies as contingent constructions of actors, inspired by competing beliefs, which are rooted in different traditions.

Decentred theory examines the ways in which patterns of rule, including both institutions and policies, are created, sustained, and modified by individuals and through their meaningful social practices. It encourages social scientists to recognise that the actions of these individuals are not fixed by a formal rationality, institutional rules, or a social logic of modernisation. On the contrary, actions arise from the beliefs individuals adopt against the background of traditions and in response to dilemmas. Decentred theory entails a shift of focus from institutions to meanings in action. It focuses attention on the diverse ways in which situated agents make and remake policies as contested practices.

Decentred theory therefore suggests that social scientists focus on a particular set of empirical topics, in this case the British healthcare governance. It focuses o...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of tables
• Notes on contributors
• 1 Decentring health policy: traditions, narratives, dilemmas
• 2 Sedimented governance in the English National Health Service
• 3 Governing professionals in a decentred state: case studies from the English National Health Service
• 4 Governing primary care: manipulated emergence, ambiguous rules and shifting incentives
• 5 Decentring patient safety governance: case studies of four English Foundation Trust Hospital Boards
• 6 Network contra network: the gap between policy and practice in the organisation of major trauma care
• 7 Patient and public involvement in the new NHS: choice, voice, and the pursuit of legitimacy
• 8 (De)politicising hospital closures in Scottish health policy 2000–2010
• 9 Congruence and incoherence: public health governance and policy in a devolved UK
• 10 Welsh health governance, or health governance in Wales
• 11 Transforming a public good into a private bad: political legitimacy, wilful deceit and the reform of the NHS in England
• Index