Article

The Blurred Boundaries between Public and Private Healthcare in the English NHS

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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

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... 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). ...
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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.
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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.
Article
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.
Article
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.
New localism in the English NHS: what is it for? Health Policy (Amsterdam)
  • P Allen
Allen, P. (2006). New localism in the English NHS: what is it for? Health Policy (Amsterdam), 79, 244-252. doi:10.1016/j.healthpol.2006.01.006
Increasing the diversity of health care providers Understanding New Labour's quasi-market reforms of the English NHS
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Allen, P., & Jones, L. (2011). Increasing the diversity of health care providers. In Mays, N., & Dixon, A. (Eds.), Understanding New Labour's quasi-market reforms of the English NHS. London, UK: The King's Fund.
The regulation of general practice1<3::AID-HPM411>3.0.CO
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Bartlett, W. (1996). The regulation of general practice. The International Journal of Health Planning and Management, 11(1), 3–18. doi:10.1002/(SICI)1099- 1751(199601)11:1<3::AID-HPM411>3.0.CO;2-N Bartlett, W., Allen, P., Perotin, V., Turner, S., Zamora, B., Matchaya, G., & Roberts, J. (2011). Provider Diversity in the NHS: Impact on Quality and Innovation. Southampton, UK: NIHR Health Reforms Evaluation Programme.
The managerial state
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Clarke, J., & Newman, J. (1997). The managerial state. London, UK: Sage.
Private hospital spend varies widely, study shows
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Clover, B. (2011). Private hospital spend varies widely, study shows. Health Service Journal. Retrieved from http://www.hsj.co.uk/news/finance/private-hospital-spend-varies-widely-studyshows/5033002.article
Hospital competition saves lives? The Economic
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Cooper, Z. Gibbons, S., Jones, S., & McGuire, A. (2011). Hospital competition saves lives? The Economic Journal, 121, F228-F260.
Organisational Costs in the New NHS: an introduction to the transaction costs and internal costs of delivering health care
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Croxson, B. (1999). Organisational Costs in the New NHS: an introduction to the transaction costs and internal costs of delivering health care. London, UK: Office of Health Economics.
Working for patients UK: HMSO. Department of Health New NHS: Modern and dependable Health Reforms in England: update and next steps
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Department of Health. (1989). Working for patients. London, UK: HMSO. Department of Health. (1997). New NHS: Modern and dependable. London, UK: HMSO. Department of Health. (2005). Health Reforms in England: update and next steps. London, UK: Department of Health.
Foundation Trusts from http://www.dh.gov.uk Department of Health
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Department of Health. (2005a). Foundation Trusts. Retrieved July 2005 from http://www.dh.gov.uk Department of Health. (2006). Health Reforms in England: update and commissioning framework.