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Abstract
In recent years it has been noted that boundaries between public and private providers of many types of welfare
have become blurred. This paper uses three dimensions of publicness to analyse this blurring of boundaries
in relation to providers of healthcare in England. The authors find that, although most care is still funded
and provided by the state, there are significant additional factors in respect of ownership and social control
which indicate that many English healthcare providers are better understood as hybrids. Furthermore, the
authors raise concerns about the possible deleterious effects of diminishing aspects of publicness on English
healthcare. The most important of these is a decrease in accountability
To read the full-text of this research, you can request a copy directly from the authors.
... We take 'hybridity' to mean the 'heterogeneous arrangements, characterized by mixtures of pure and incongruous origins, (ideal)types, "cultures", "coordination mechanisms", "rationalities", or "action logics"' (Brandsen et al. 2005, p. 750) influencing organizational behaviour. Hybrid forms of organization are not restricted to private sector companies engaging in joint-ventures, strategic partnering or other networks, but are today a common form of organizing public services, including social housing (Koffijberg et al. 2012), healthcare (Allen et al. 2011), and broadcasting (Turner and Lourenço 2012). The hybridization of the public and private sectors emphasizes the interdependence of private and public interests, and the resultant need for studies that explore the interaction between these interests and their influence on organizational behaviour (Mahoney et al. 2009). ...
... Bozeman (1987) suggests that the 'publicness' of both public and private organizations depends upon the relative influence of economic and political authority on different organizational processes, including funding sources and regulation. In relation to the English NHS, supply-side reforms have encouraged 'hybrid' providers with a variety of ownership structures, funding sources, and modes of social control that bring together aspects of market and political hierarchy (Allen et al. 2011). In UK broadcasting, changes in the late 1990s to Channel 4's funding structure (the UK's only public service publisher-broadcaster) allowed profits to be retained from its advertising, which resulted in the channel taking on a more commercial orientation and becoming less pluralistic in its programming (Born 2003). ...
Many countries use state-owned, for-profit, and third sector organizations to provide public services, generating ‘hybrid’ organizational forms. This article examines how the hybridization of organizations in the public sector is influenced by interaction between regulatory change and professional communities. It presents qualitative data on three areas of the UK public sector that have undergone marketization: healthcare, broadcasting, and postal services. Implementation of market-based reform in public sector organizations is shaped by sector-specific differences in professional communities, as these groups interact with reform processes. Sectoral differences in communities include their power to influence reform, their persistence despite reform, and their alignment with the direction of change or innovation. Equally, the dynamics of professional communities can be affected by reform. Policymakers need to take account of the ways that implementation of hybrid forms interacts with professional communities, including risk of disrupting existing relationships based on communities that contribute to learning.
IMPACT
This article suggests why a different approach may be required for commissioning services from third sector providers than from, say, corporate or public providers. English systems for commissioning third sector providers contain both commodified elements (for example formal procurement, provider competition, commissioner–provider separation) and collaborative, relational elements (for example long-term collaboration, reliance on inter-organizational networks). When the two elements conflicted, commissioners and third sector organizations tended to try to work around the commodified elements in order to preserve and develop the collaborative aspects, which suggests that, in practice, they find de-commodified, collaborative methods better adapted to the commissioning of third sector organizations.
ABSTRACT
When publicly-funded services are outsourced, governments still use multiple governance structures to retain some control over the services provided. Using realist methods the authors systematically compared this aspect of community health activities provided by third sector organizations in six English localities during 2020–2022. Two modes of commissioning coexisted. Commodified commissioning largely embodied Washington consensus models of formal, competitive procurement. A contrasting, collaborative mode of commissioning relied more upon relational, long-term co-operation and networking among organizations. When the two modes conflicted, commissioners often favoured the collaborative mode and sought to adjust their commissioning to make it less commodified.
Since 1990, market mechanisms have occurred in the predominantly hierarchical NHS. The Health and Social Care Act 2012 led to concerns that market principles had been irrevocably embedded in the NHS and that the regulators would acquire unwarranted power compared to politicians (known as ‘juridification’). In order to assess this concern, we analysed regulatory activity in the period from 2015 to 2018. We explored how economic regulation of the NHS had changed in the light of the policy turn back to hierarchy in 2014 and the changes in the legislative framework under the Public Contracts Regulations 2015. We found the continuing dominance of hierarchical modes of control was reflected in the relative dominance and behaviour of the sector economic regulator. But there had also been a limited degree of juridification involving the courts. Generally, the regulatory decisions were consistent with the 2014 policy shift away from market principles and consistent with the enduring role of hierarchy in the NHS, but the existing legislative regime did allow the incursion of pro market regulatory decision making, and instances of such decisions were identified.
Eager to learn from private sector trends, practitioners in (semi)public organizations across the world have recently turned their eyes to the concept of work engagement to improve employee performance. Studies in the private sector show that work engagement is a more robust predictor of performance than, for example, satisfaction. The goal of this study is to find out whether the effects of work engagement on attitudinal, behavioral, and performance outcomes within the semipublic and public sector are also as high as expected and whether these relationships differ between the public, semipublic, and private sector. The results of the cross-sectoral meta-analysis of 130 studies showed that the most noticeable significant sectoral differences can be found in the mean work engagement and the effects of work engagement on the level of attitudinal outcomes (job satisfaction and commitment) and behavioral outcomes (workaholism and turnover intention).
Purpose
This paper aims to critically explore hybrid organisations in health care. It examines the broad literature on hybrids focusing on issues of perspective, definition, sub-type and level. It then presents the results of the literature review of hybrid health care organisations, exploring which organisations have been viewed as hybrids, and then examining studies in more detail with respect to the research questions.
Design/methodology/approach
It critically explores the literature on hybrid organisations in health care through a structured search.
Findings
It is found that a wide variety of hybrid forms exist, but not clear what they combine or how they combine it. However, the level of depth from some of these studies is rather limited, with little consensus on definition, and relatively few drawing on any explicit conceptual perspective. It seems that the wider hybridity literatures have limited influence of studies of hybrid health care organisations.
Originality/value
As far as we are aware, this paper is the first attempt to critically review the literature on hybrid organisations in health care. . It is concluded that it is difficult to define and explain hybrid health care organisations. Health care hybrids appear to be chameleons as they appear to be able to change their form to different observers.
Since the beginning of the 1990s the public healthcare system in England has been subject to reforms. This has resulted in a structurally hybrid system of public service with elements of the market. Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) managers' views on competition and cooperation as mechanisms for commissioning health services. We interrogate the extent of institutional change in the NHS by examining managers' understanding of the formal rules, normative positions and frameworks for action under the regime of the Health and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative approaches, but also evidence of marketization in the normative outlook and actions. This suggests that hybridity in the NHS has already spread from structure and rules to other institutional pillars. The study showed that managers were adept at navigating the complex policy environment despite its inherent contradictions.
Social enterprises have been actively encouraged to spin out of the National Health Service (NHS) on the grounds that they can deliver more innovative, cost-efficient and responsive services. This is arguably achieved through a combination of the best of the public, third and private sectors. This article explores this idea by bringing together empirical data from interviews with NHS spin-outs and a framework of ‘publicness’. By focusing on NHS spin-outs, we look at what happens to an organization’s publicness when it leaves the public sector yet continues to deliver publicly funded services.
This paper reports an exploratory study utilising a publicness model in which the impact of ownership, funding and mode of control on performance is moderated by organisational characteristics such as goals, structure and management. It describes the testing in 164 English hospital pharmacies of four health sector-relevant characteristics; diffusion of ownership (number of owners), priority of financial goals, congruence of core purpose (goals of sub-unit compared to organisation), and proximity of control (hierarchical levels between sub-unit and top management). Associations between these and four indicators of performance (managerial effectiveness, utilisation of human resources, work quality and employee satisfaction) were examined. Statistically significant relationships were seen between three of the organisational characteristics and some aspect of performance. Priority of financial goals was associated with perceptions of managerial performance, and proximity of control with use of human resources, work quality and employee satisfaction. Further elucidation of such characteristics may be justified.
The purpose of this paper is to reflect on social enterprise as an organisational form in health organisation and management.
The paper presents a critique of the underlying assumptions associated with social enterprise in the context of English health and social care.
The rise of social enterprise models of service provision reflects increasingly hybrid organisational forms and functions entering the health and social care market. Whilst at one level this hybridity increases the diversity of service providers promoting innovative and responsive services, the paper argues that further inspection of the assumptions associated with social enterprise reveal an organisational form that is symbolic of isomorphic processes pushing healthcare organisations toward greater levels of homogeneity, based on market-based standardisation and practices. Social enterprise forms part of isomorphic processes moving healthcare organisation and management towards market norms".
In line with the aim of the "New Perspectives section", the paper aims to present a provocative perspective about developments in health and social care, as a spur to further debate and research in this area.
Scholars have devoted increasing attention to similarities and differences between public and private organizations. This paper critiques the comparative literature on these organizations in order to assess the usefulness of the public-private distinction in organization theory and concludes that further analysis of this distinction is valuable. Several avenues for improving research are suggested, including clarification of the categories through an extension of previous conceptions, and assessment of a proposed typology of subcategories across the public-private continuum.
This review examines the nature and application of decentralisation as an organisational model for health care in England. The study reviews the relevant theoretical literature from a range of disciplines relating to different public- and private-sector contexts of decentralisation and centralisation. It examines empirical evidence about decentralisation and centralisation in public and private organisations and explores the relationship between decentralisation and different incentive structures, which, in turn affect organisational performance.
The provision and governance of personal social services is nowadays often thought as a matter of finding the right balance between market principles and state regulation. However often, personal social services depend as well from a third resource and mechanism of governance: It is the impact of the social capital of civil society, which makes itself felt not only by resources such as grants, donations, and volunteering, but as well by networking and social partnerships. A number of crucial changes in welfare and service provision have led to a situation, where service systems and service units, rather than being part of a clear-cut sector, have increasingly to be seen as hybrids, combining varying balances of resources and mixes of governance principles usually associated with the market, the state, and the civil society. Presented at the Sixth International Conference of the International Society for Third-Sector Research, Ryerson University and York University, Toronto, Canda, July 11–14, 2004.
Using patient experience survey data, the paper investigates whether hospital ownership affects the level of quality reported by patients whose care is funded by the National Health Service in areas other than clinical quality. We estimate a switching regression model that accounts for (i) some observable characteristics of the patient and the hospital episode; (ii) selection into private hospitals; and (iii) unmeasured hospital characteristics captured by hospital fixed effects. We find that the experience reported by patients in public and private hospitals is different, i.e. most dimensions of quality are delivered differently by the two types of hospitals, with each sector offering greater quality in certain specialties or to certain groups of patients. However, the sum of all ownership effects is not statistically different from zero at sample means. In other words, hospital ownership in and of itself does not affect the level of quality of the average patient's reported experience. Differences in mean reported quality levels between the private and public sectors are entirely attributable to patient characteristics, the selection of patients into public or private hospitals and unobserved characteristics specific to individual hospitals, rather than to hospital ownership.
In England recent health reforms have resulted in a shift of emphasis from targets to outcomes, and to the provision of healthcare by any willing provider. The outcomes described encompass clinical and public service outcomes such as choice and access. The range of organisations providing healthcare services is large and increasing. Whilst many are clearly located in either the public or private sectors, others have features of both public and private organisations, and are not easily characterised as either one or the other. Analytical frameworks are generally underdeveloped, and have not kept pace with changes in organisation forms. This article reviews how public and private organisations have been compared in organisation theory, describes previous work on dimensional publicness in both non-healthcare and healthcare organisations, and presents a publicness grid for hospitals in England. Publicness is defined as a characteristic of an organisation which reflects the extent to which the organisation is influenced by political authority. In establishing a link between publicness and public service outcomes it is suggested that core publicness, dimensional publicness (consisting of political and economic authority) and normative publicness (public sector values) all have to be taken into account, since all have an impact on these outcomes. A framework is described that can be used to map the relationships between public service outcomes and publicness. How the framework can be applied in practice to healthcare organisations is described through the development of appropriate indicators and measures. Publicness theory can help health administrators and researchers understand and better manage public service outcomes. Some of the research questions that might be addressed using this approach are considered. Further development of the publicness concept in healthcare is advocated.
There has been considerable concern expressed about the outcomes achieved in Independent Sector Treatment Centres (ISTCs) introduced in England since 2003. Our aim was to compare the case-mix and patients' reported outcomes of surgery in ISTCs and in NHS providers.
Prospective cohort study of 769 patients treated in six ISTCs and 1895 treated in 20 NHS providers (acute hospitals and treatment centres) in England during 2006-07. Participants underwent one of three day surgery procedures (inguinal hernia repair, varicose vein surgery, cataract extraction) or hip or knee replacement. Change in patient-reported health status and health related quality of life (measured using a disease-specific and a generic (EQ-5D) instrument) was assessed either 3-months (day surgery) or 6-months (hip/knee) after surgery. In addition patient-reported post-operative complications and an overall assessment of success of surgery were collected. Outcome measures were adjusted (using multivariable regression) for patient characteristics (disease severity, duration of symptoms, age, sex, socioeconomic status, general health, previous similar surgery, comorbidity).
Post-operative response rates varied by procedure (73%-88%) and were similar for those treated in ISTCs and NHS facilities. Patients treated in ISTCs were healthier, were less likely to have any comorbidity and, for those undergoing cataract surgery or joint replacement, their primary condition was less severe. Those undergoing hernia repair or joint replacement were less likely to have had similar surgery before. When adjustment was made for pre-operative characteristics, patients undergoing cataract surgery or hip replacement in ISTCs achieved a slightly greater improvement in functional status and quality of life than those treated in NHS facilities, while the opposite was true of patients undergoing hernia repair. No significant differences were found for the two other procedures. Patients treated in ISTCs were less likely to report post-operative problems than those treated in NHS facilities for cataract surgery (Adjusted Odds Ratio 0.35; 95% CI 0.17-0.70), hernia repair (0.42; 0.28-0.63) and knee replacement (0.44; 0.28-0.69). Most patients described the result of their operation as excellent, very good or good, regardless of where they were treated.
The case-mix of patients treated in ISTCs differs from that in NHS providers, in line with the intention of the contracts. Caution is needed in interpreting the observation that patients treated in ISTCs reported slightly better outcomes as very few ISTCs participated, case-mix adjustment might have been insufficient, and patients' reports might have been biased as they were more likely to be satisfied with the way they were treated.
Recombinant property is a form of organizational hedging in which actors respond to uncertainty by diversifying assets, redefining and recombining resources. It is an attempt to hold resources that can be justified by more than one legitimating principle. Property transformation in postsocialist Hungary involves the decentralized reorganization of assets and the centralized management of liabilities. Together they blur the boundaries of public and private, the boundaries of enterprises, and the boundedness of justificatory principles. Enterprise-level field research, data on the ownership structure of Hungary's 220 largest enterprises and banks, and an examination of the government's recent debt consolidation programs suggest the emergence of a distinctively East European capitalism that will differ as much from West European capitalisms as do contemporary East Asian variants.
This paper does not purport to provide any straightforward answer to the question posed. Instead I shall raise a series of further questions and draw a number of distinctions which underpin discussion of the accountability of voluntary organisations. I shall then consider some of the potential difficulties faced by voluntary organisations in responding to demands for greater accountability.
This article analyses the diversity of public organizations focusing on variations in their degree of publicness. We define 'publicness' as organizational attachment to public sector values: for example, due process, accountability, and welfare provision. Based on a survey of Danish public organizations, we show that organizations with a high degree of publicness differ from organizations with a low degree of publicness. The former are characterized by complex tasks, professional orientation, many external stakeholders, conflicting environmental demands, and low managerial autonomy. The latter are the opposite. We explore in detail both the relationship between the organizations and their parent ministries and their responses to organizational change. Organizations with a high degree of publicness are subject to a tight ministerial control and have formal and distant relations with the ministry. They also have strong vertical links, externally and internally. High internal control is the joint product of ministerial control and the stress on the public sector value of rule compliance. All organizations ranked high on publicness are reluctant to adopt organizational changes stemming from the 'New Public Management'. Again, organizations with a low degree of publicness are the opposite, keen to adopt new ideas. We show that degree of publicness matters, across both functional types of organizations and policy sectors. Finally, we discuss alternative theoretical explanations of publicness drawn from contingency theory and the new institutionalism.
Introduction 1. Understanding the Dynamics of Change in the Health Care Arena PART I: EPISODES OF POLICY CHANGE 2. The Establishment of the Welfare State in the Health Care Arena 3. The Reforms of the 1990s 4. Ideas, Institutions, Interests, and Actors and the Accidents of Policy Episodes PART II: THE DISTINCTIVE LOGICS OF NATIONAL SYSTEMS 5. The US: The Logic of the Mixed Market 6. Britain: The Logic of Corporatism Meets the Internal Market 7. Canada: The Logic of the Single-Payer System 8. Conclusion References Index
Public management theory generally assumes that public and private organizations' decisions and decision processes differ. However, surprisingly little research has identified specific, empirically-derived differences and similarities. Seeking to fill this gap between research and theory, this study examines the influence of publicness on types of strategic decisions encountered by managers. Two different concepts of publicness are examined, one based on organizations' legal status or ownership, the other a dimensional concept whereby organizations can be more or less public depending on the degree of external political control of their resources and activities. Drawing upon data from a mail survey of 210 upper managers in 39 organizations, the analysis indicates that (1) publicness has a small influence on the types of strategic decisions addressed; (2) publicness is associated with greater decision participation but not smoothness; and (3) the ownership concept of publicness is important in accounting for differences in strategic decision making, but the dimensional publicness concept accounts for differences beyond those attributable to ownership alone.
When health professionals offer primary health services on a private market a number of problems can arise to do with choice, quality and supplier-induced demand. Professional self-regulation through qualification requirements and licensing procedures may offset some of the worst problems. However, in the UK, the primary health care sector is also subject to additional regulatory controls set within the context of the NHS. Private practitioners within the NHS function in a quasi-market setting, in which they are funded by public health authorities to provide services free at the point of delivery to their patients. Within this context there is regulation of quality, entry, prices and profits. This system can be contrasted with the much less extensive set of regulations applied to more market-based systems operating in countries such as the USA. Recent reforms in the UK have, however, initiated a movement towards a market-led system, extended the autonomy of health care practitioners, and increased the scope of financial incentives as a mechanism to promote professional quality and innovation. This article draws on the insights developed in Propper (1993) in her study of regulation and quasi-markets in secondary health care, education and community care. Its focus is on the extent of regulation in primary health care services; the effects of increased financial incentives on professional performance brought about by the NHS reforms; and, the scope for further deregulation of professional services in primary care.
Recent reforms in the organization of the National Health Service (NHS) have introduced market‐type relationships between purchasers and providers, based largely on long‐term contracts, in an attempt to improve the cost‐effectiveness of health service delivery. The proponents of the new arrangements argue that efficiency will be stimulated via the incentive effects of competition. However, any such gains from the introduction of quasi‐markets are likely to be offset by the substantial transaction costs associated with the operation of markets characterized by uncertainty, bounded rationality and imperfect information. This paper analyses the sources of the transaction costs which are likely to arise, in the context of the various types of contract design available to the new quasimarket in health service delivery.
Political changes in the United States have produced several conflicting pressures on the public bureaucracy. On the one hand, the Reagan administration placed greater demands for political responsive ness on civil servants; those pressures continued to a lesser degree in the Bush administration. At the same time, there are increasing pressures on civil servants from clients and interest groups for attention to their needs and demands. All these groups also seek to hold civil servants accountable, although in different ways.
The public is often caught in the middle, and individual organizations may experience internal tensions arising from these conflicting demands. The public bureaucracy itself is composed of well-educated and commit ted individuals who seek their own role in defining and implementing policy. These policy and managerial conflicts are not peculiar to the United States but are found in most modern democracies.
In recent years, there has been an increasing interest in - though an insufficient understanding of - changes in the governance of welfare and related governance regimes, with the latter being conceptualized as systems of multifaceted inter-agency relations and associated modes of coordination. Referring to evidence from France, Britain and Germany, the article explores these changes with an eye on the role of voluntary organizations within these regimes. It challenges widespread typologies of ‘welfare mixes’ as well as general assumptions about international variation. It argues that, throughout Western Europe, similar governance regimes emerged in the postwar settlement, materializing in an ‘organized welfare mix’. It then illustrates how these regimes currently undergo a process of permanent dis- and reorganization, again irrespective of international differences. Long- established patterns of a system-wide coordination via negotiated public-private partnerships turn into volatile configurations, with a growing albeit varying influence of the market rationale. Moreover, there is an increasing distance between voluntary provider organizations and both the welfare state and civil society, with this entailing precarious, but also more dynamic interrelations. Finally, civic action becomes more fluid, sporadic, dispersed but also more creative in many places. Hence, there is the paradox of the new welfare mixes exhibiting innovative dynamics and systematic organizational failure at the same time, with (more) output heterogeneity as an inevitable consequence.
While the boundaries between different sectors within the welfare mix have always been indistinct, increasing involvement of third sector organisations (TSOs) in government contracts has accentuated the 'blurring' of these boundaries over recent decades. This paper builds on existing analyses of hybridity in the third sector and presents the welfare pyramid as a theoretical framework within which hybridisation and its implications for TSOs of different types can be explored. Taking homelessness TSOs as an example, it highlights the existence of a division of labour among these organisations (which seems to have been exacerbated by contracting) and underlines the need for policy makers to carefully consider TSOs'varied roles, strengths andl imitations.
This article analyses the diversity of public organizations focusing on variations in their degree of publicness. We define ‘publicness’ as organizational attachment to public sector values: for example, due process, accountability, and welfare provision. Based on a survey of Danish public organizations, we show that organizations with a high degree of publicness differ from organizations with a low degree of publicness. The former are characterized by complex tasks, professional orientation, many external stakeholders, conflicting environmental demands, and low managerial autonomy. The latter are the opposite. We explore in detail both the relationship between the organizations and their parent ministries and their responses to organizational change. Organizations with a high degree of publicness are subject to a tight ministerial control and have formal and distant relations with the ministry. They also have strong vertical links, externally and internally. High internal control is the joint product of ministerial control and the stress on the public sector value of rule compliance. All organizations ranked high on publicness are reluctant to adopt organizational changes stemming from the ‘New Public Management’. Again, organizations with a low degree of publicness are the opposite, keen to adopt new ideas. We show that degree of publicness matters, across both functional types of organizations and policy sectors. Finally, we discuss alternative theoretical explanations of publicness drawn from contingency theory and the new institutionalism.
Introducing market-like structures to public services is a key aspect of New Public Management. The restructuring of the NHS into an internal market of the 1990s is an example. Recent policies have further developed this notion. A new aspect of the restructuring is a focus on increasing the diversity of types of provider of healthcare organisations. The objectives of the restructuring policy entailing the increase in supply side diversity are examined, and the challenges raised by these changes are discussed. It is argued that the government is too optimistic about the benefits, and insufficiently concerned about possible undesirable consequences.
In this article, it is argued that while there has been an apparent eclipse in discourse regarding the publicness or public quality of public service, the recent transition toward a market-driven mode of governance has created a serious challenge to such publicness. More specifically, the contemporary businesslike changes in the objectives, structures, functions, norms, and users of public service tend to diminish its publicness in terms of its current trends toward eroding public-private distinction, shrinking socioeconomic role, narrowing composition of service recipients, worsening condition of accountability, and declining level of public trust. Based on the existing studies, empirical findings, and country experiences, this article delineates the basic criteria determining the publicness of public service, uses these criteria to demonstrate how the recent businesslike reforms have led to the erosion of such publicness, and makes recommendations for reviving the quality of publicness in public service.
This book charts the significant increase in Britain over the last 25 years in the deployment of contract as a regulatory mechanism across a broad spectrum of social relationships. Since Labour came to power in 1997 the trend has accelerated, the use of contract spreading beyond the sphere of economics into public administration and social policy. 'New public contracting' is the term given to this distinctive mode of governance, characterised by the delegation of contractual powers and responsibilities to public agencies in regulatory frameworks preserving central government controls and powers of intervention. In many cases the contracts are not legally enforceable, their power as regulatory instruments deriving from the hierarchical authority relations in which they are embedded. Examples of the new public contracting include the regulation of relationships between government departments through Public Service Agreements and Framework Documents; the regulation of relationships between individual citizens and the state through Youth Offender Contracts, Parenting Contracts, and Jobseekers Agreements; the funding of public infrastructure projects through Public-Private Partnerships; and the restructuring of key public-service sectors such as health, social care, and education through contracts in competitive quasi-markets, reflecting the Government's privatisation agenda. The book critically analyzes and evaluates such contractual arrangements with reference to theories of relational contract and responsive regulation. It argues that while in business and other private relations contract routinely enables the parties to regulate and adjust their on-going relationships to mutual benefit, this is often not the case in the new public contracting.
A wide ranging set of reforms is being introduced into the English National Health Service (NHS). They are designed to increase the market-like behaviour of providers of care with a view to improving efficiency, quality and responsiveness of services. This paper is concerned with one aspect of those reforms: namely the policy to increase the diversity of types of providers of care to NHS patients. In this context, increasing diversity means that providers will not all be standard publicly owned NHS organizations. They can be publicly owned but autonomous, or independent (both in for-profit and not for profit). The paper discusses the wide range of organizational forms available, analyzing their governance structures It then discusses the small amount of evidence currently available about the performance of diverse providers of health care.
The objective of this paper is to explain and illustrate the complex relationship between ownership arrangements and enterprise performance. It is commonly argued that efficiency will be lower in the public sector than the private because enterprise objectives deviate from maximisation of profits and because monitoring arrangements are inadequate due to the absence of capital market discipline. We argue that public ownership does make the owner-manager relationship more complicated because the chain of principals and agents is expanded; objectives are politically determined; and these are conveyed by a policy-making administrative structure to management. But the relative efficiency of public as against private ownership actually depends on the efficacy of capital market monitoring: on the political and constitutional system; on the information and sanctions available to policy makers; and on the nature of the management market. Variation in these factors can help to explain the different natures and roles of the public sector between countries.
To investigate the external and internal governance of NHS foundation trusts (FTs), which have increased autonomy, and local members and governors unlike other NHS trusts.
In depth, three-year case studies of four FTs; and analysis of national quantitative data on all FT hospitals and NHS Trust hospitals to give national context. Data included 111 interviews with managers, clinicians, governors and members, and local purchasers; observation of meetings; and analysis of FTs' documents.
The four case study FTs were similar to other FTs. They had used their increased autonomy to develop more business-like practices. The FT regulator, Monitor, intervened only when there were reported problems in FT performance. National targets applying to the NHS also had a large effect on FT behaviour. FTs saw themselves as part of the local health economy and tried to maintain good relationships with local organisations. Relationships between governors and the FTs' executives were still developing, and not all governors felt able to hold their FT to account. The skills and experience of staff members and governors were under-used in the new governance structures.
It is easier to increase autonomy for public hospitals than to increase local accountability. Hospital managers are likely to be interested in making decisions with less central government control, whilst mechanisms for local accountability are notoriously difficult to design and operate. Further consideration of internal governance of FTs is needed. In a deteriorating financial climate, FTs should be better placed to make savings, due to their more business-like practices.
To assess the impact of provider diversity on quality and innovation in the English NHS by mapping the extent of diverse provider activity and identifying the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organizations within the NHS, and the factors that affect the entry and growth of new providers.
Case studies of four local health economies. Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and third sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009.
Involvement of diverse providers in the NHS is limited. Commissioners' local strategies influence degrees of diversity. Barriers to entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS trusts to respond by making improvements. Information sharing diminishes as competition intensifies.
There is scope to increase the participation of diverse providers in the NHS but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.
Over the past two decades, an international trend of exposing public health services to different forms of economic organisation has emerged. In the English National Health Service (NHS), care is currently provided through a quasi-market including 'diverse' providers from the private and third sector. The predominant scheme through which private sector companies have been awarded NHS contracts is the Independent Sector Treatment Centre (ISTC) programme. ISTCs were designed to produce innovative models of service delivery for elective care and stimulate innovation among incumbent NHS providers. This paper investigates these claims using qualitative data on the impact of an ISTC upon a local health economy (LHE) composed of NHS organisations in England. Using the case of elective orthopaedic surgery, we conducted semi-structured interviews with senior managers from incumbent NHS providers and an ISTC in 2009. We show that ISTCs exhibit a different relationship with frontline clinicians because they counteract the power of professional communities associated with the NHS. This has positive and negative consequences for innovation. ISTCs have introduced new routines unencumbered by the extant norms of professional communities, but they appear to represent weaker learning environments and do not reproduce cooperation across organisational boundaries to the same extent as incumbent NHS providers.
The paper begins with a brief overview of the theory of incentives, with special attention to issues that are important in the public sector, in general and human capital in particular. It then reviews some case studies and empirical studies of incentives in the public sector, examining how these studies relate to the theory. Some implications for reform and design of organizations are drawn.
This work provides a comprehensive critical evaluation of the quasi-market revolution in social policy viewed across the whole range of sectors in which recent reforms have taken place including competitive tendering, education, health and community care.
This paper analyzes the behavior of U. S. governors from 1950 to 1986 to investigate a reputation-building model of political
behavior. We argue that differences in the behavior of governors who face a binding term limit and those who are able to run
again provides a source of variation in discount rates that can be used to test a political agency model. We find evidence
that taxes, spending, and other policy instruments respond to a binding term limit if a Democrat is in office. The result
is a fiscal cycle in term-limit states, which lowers state income when the term limit binds.
The splitting of the functions of purchaser and provider in the New Zealand health system in 1993 necessitated the use of explicit contracts between the two parties. This paper examines contracting experiences during the first two years of operation. The study focuses on four services: rest homes, primary care clinics, surgical services, and acute mental health services. The insights of transaction cost economics form the theoretical framework. The objective of this study was to examine whether the transaction costs associated with contracting vary across the four different services, and whether different types of contracts and contractual relationships are emerging as transactors attempt to reduce these costs. Information was collected in a series of 53 interviews with purchasers and providers, together with any relevant documentation. The results suggest that the costs of contracting are indeed greater for some services than for others. Other variables such as the style of negotiations, the type and specificity of contracts and the degree of monitoring also differ across the four services. At this early stage of the reform process, there was little evidence that purchasers and providers were attempting to reduce transaction costs by negotiating more flexible, longer-term, relational contracts. The main benefit from contracting to date has been improved accountability of service providers.
The British National Health Service (NHS) before its 1990s internal-market reforms was a gridlock of perverse incentives. The internal market, an attempt to introduce some market incentives, stimulated much innovation in primary care commissioning and practice improvement and led to increased efficiency. However, its effects were quite limited, because the essential conditions for a market to operate were not fulfilled. There now exists a crisis of confidence in the quality of care in the NHS. It is doubtful whether a culture of innovation, efficiency, and good customer service is possible in a public-sector monopoly whose services are in excess demand and whose units do not get more resources for caring for more patients. It also is doubtful whether the NHS can modernize without consumer choice, competition, and more resources.
This paper uses a natural experiment approach to identify the effects of an exogenouschange in future pension benefits on workers’ training participation. We use uniquematched survey and administrative data for male employees in the Dutch public sectorwho were born in 1949 or 1950. Only the latter were subject to a major pension reformthat diminished their pension rights. We find that this exogenous shock to pension rightspostpones expected retirement and increases participation in training courses amongolder employees, although exclusively for those employed in large organizations.
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