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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.11.011 Byline: Rod Sheaff (a), Lawrence Benson (b), Lou Farbus (a), Jill Schofield (c), Russell Mannion (d), David Reeves (e) Abstract: Many health systems now use networks as governance structures. Network 'macroculture' is the complex of artefacts, espoused values and unarticulated assumptions through which network members coordinate network activities. Knowledge of how network macroculture during 2006-2008 develops is therefore of value for understanding how health networks operate, how health system reforms affect them, and how networks function (and can be used) as governance structures. To examine how quasi-market reforms impact upon health networks' macrocultures we systematically compared longitudinal case studies of these impacts across two care networks, a programme network and a user-experience network in the English NHS. We conducted interviews with key informants, focus groups, non-participant observations of meetings and analyses of key documents. We found that in these networks, artefacts adapted to health system reform faster than espoused values did, and the latter adapted faster than basic underlying assumptions. These findings contribute to knowledge by providing empirical support for theories which hold that changes in networks' core practical activity are what stimulate changes in other aspects of network macroculture. The most powerful way of using network macroculture to manage the formation and operation of health networks therefore appears to be by focusing managerial activity on the ways in which networks produce their core artefacts. Author Affiliation: (a) University of Plymouth, Plymouth, Devon, United Kingdom (b) Manchester Business School, Manchester University, United Kingdom (c) University of Edinburgh, United Kingdom (d) University of York, United Kingdom (e) National School for Health Research (NIHR) School for Primary Care Research, Manchester University, United Kingdom

The English NHS has been repeatedly restructured since 1991. Drawing on multiple case studies in English primary health care from 1998 to 2005 and on (other) published studies, this article uses Therborn's theory of power to make a framework analysis of how these reforms redistributed power between medicine and management in NHS primary care. Legal changes ended the GP monopoly of primary medical care provision and, with greater managerial discretion in NHS spending, allowed more diverse organisational forms of primary care provision to appear, although general practice remained predominant. Changes in managerial and professional ideologies relaxed the restrictions on managerial decisions about general practice. Re-negotiations between the medical profession and the state mostly tended to increase managerial power. Evidence-based medicine has tended to weaken the impersonal sources of medical power. On balance, these events have tended to increase managerial power over medical practice. They also suggest adjustments to Therborn's conceptualisation of power.

Hirschman contrasts exit and voice as 'recuperation' mechanisms for making organisations responsive to users. However, the emergence of health-care quasi-markets and of network governance structures since Hirschman necessitate revising his theory, for they complicate the relationships between governance structures and recuperation mechanisms. Using a case study of nine primary care trusts (PCTs), this paper analyses the recuperation mechanisms, governance structures and relations between them in primary care in England. User voice can be exercised through dedicated networks besides hierarchies. As well as the 'user exit' described by Hirschman, two new 'exit' mechanisms now exist in quasimarkets. Commissioner exit occurs when a third-party payer stops using a given provider. Professional proxy exit occurs when a general practitioner (GP) fund-holder (or analogous budget-holder) behaves similarly. Neither exit mechanism requires the existence of mechanisms for user exit from healthcare purchasers, provided strong voice mechanisms exist instead to make commissioners responsive to users' demands. Establishing such voice mechanisms is not straightforward, however, as the experience of English PCTs illustrates. Keywords: Exit; Voice; Governance; Primary care; England; Quasi-market; UK

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.12.016 Byline: Susan Pickard (a), Rod Sheaff (b), Bernard Dowling (a) Keywords: Exit; Voice; Governance; Primary care; England; Quasi-market; UK Abstract: Hirschman contrasts exit and voice as 'recuperation' mechanisms for making organisations responsive to users. However, the emergence of health-care quasi-markets and of network governance structures since Hirschman necessitate revising his theory, for they complicate the relationships between governance structures and recuperation mechanisms. Using a case study of nine primary care trusts (PCTs), this paper analyses the recuperation mechanisms, governance structures and relations between them in primary care in England. User voice can be exercised through dedicated networks besides hierarchies. As well as the 'user exit' described by Hirschman, two new 'exit' mechanisms now exist in quasi-markets. Commissioner exit occurs when a third-party payer stops using a given provider. Professional proxy exit occurs when a general practitioner (GP) fund-holder (or analogous budget-holder) behaves similarly. Neither exit mechanism requires the existence of mechanisms for user exit from healthcare purchasers, provided strong voice mechanisms exist instead to make commissioners responsive to users' demands. Establishing such voice mechanisms is not straightforward, however, as the experience of English PCTs illustrates. Author Affiliation: (a) National Primary Care Research and Development Centre, Manchester University, Williamson Building, Oxford Road, Manchester M13 9PL, UK (b) School of Health Professions, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK

Epidemiological, demographic and environmental crises, transition to a new political regime and exceptionally severe economic crises were powerful stimuli to health sector reform in Russia. The Russian Federation responded by introducing medical insurance whilst decentralising public administration. Yet despite intense contextual pressures to do so and a new policy climate, Russian hospitals found it difficult to reprofile services and reallocate their resources. A case study analysing governance structures in Sverdlovsk oblast reveals that medical insurance created incentives to reduce costs by reducing bed-days, but if hospitals did so they would lose money under the formulae through which decentralised local government still allocated around three-quarters of hospital income. If instead hospitals tried to increase budgetary income by increasing numbers of bed-days, the insurance system would penalise them. This specific form of policy mess can be called 'governance in gridlock'. The juxtaposition of two overlapping but incompatible sets of governance structures practically immobilised official hospital management systems. It is as one-sided to blame residues of the Soviet system for this gridlock as it is to blame the medical insurance system. Gridlock resulted from the interaction of the two, a problem to which all health system reform is potentially vulnerable. Keywords: Decentralisation; Governance; Gridlock; Health insurance; Hospital management; Russia; Soviet Union

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2004.10.008 Byline: Rod Sheaff Keywords: Decentralisation; Governance; Gridlock; Health insurance; Hospital management; Russia; Soviet Union Abstract: Epidemiological, demographic and environmental crises, transition to a new political regime and exceptionally severe economic crises were powerful stimuli to health sector reform in Russia. The Russian Federation responded by introducing medical insurance whilst decentralising public administration. Yet despite intense contextual pressures to do so and a new policy climate, Russian hospitals found it difficult to reprofile services and reallocate their resources. A case study analysing governance structures in Sverdlovsk oblast reveals that medical insurance created incentives to reduce costs by reducing bed-days, but if hospitals did so they would lose money under the formulae through which decentralised local government still allocated around three-quarters of hospital income. If instead hospitals tried to increase budgetary income by increasing numbers of bed-days, the insurance system would penalise them. This specific form of policy mess can be called 'governance in gridlock'. The juxtaposition of two overlapping but incompatible sets of governance structures practically immobilised official hospital management systems. It is as one-sided to blame residues of the Soviet system for this gridlock as it is to blame the medical insurance system. Gridlock resulted from the interaction of the two, a problem to which all health system reform is potentially vulnerable. Author Affiliation: National Primary Care Research and Development Centre, Manchester University, Williamson Building, Oxford Road, Manchester, M13 9PL, UK

Analyses and policy statements about publicly funded services frequently distinguish `demands' from `needs'. The distinction has been challenged, calling into question the coherence of formulating welfare policy and evaluating public services in terms of needs. This paper explicates the conceptual distinction between demands and needs in terms of derived demand and information asymmetry. `Needs' can be defined as `rational demands', where `rational' means `consistent and evidence-based', and `demands' as `desires' rather than `effective (i.e. economic) demand'. On that basis, practical demand management in needs-based public services would require: 1. Knowledge of users' demands for services; 2. Content analyses of users' demands to identify any misinformed demands; 3. Conversion of any misinformed demands into evidence-based specifications of needs; 4. Formulating coherent, evidence-based demands on behalf of users who cannot to do so themselves. A study of English NHS Primary Care Groups explores the problems which authorities responsible for publicly funded services face in undertaking these activities. Demand management receives low priority in terms of the incentives and intellectual resources applied to it. Needs assessment has higher priority but is regarded as a branch of evidence-based professional practice, controlled by professionals rather than responsive to users. This separation tends to defeat the purposes of needs-based public services.

Survival of the public service ethos in Britain has been called into question following introduction of the `new public management' and marketizing reforms in much of the public sector. This article examines how these developments have occurred in the NHS, using survey data to analyse NHS board members' substantive ethical values. Unexpectedly the results suggest that NHS board members with a predominantly NHS background appear less ethically conservative, more flexible and less risk-averse than those recruited from non-NHS backgrounds; and that as yet the NHS management `culture' is not very homogenous in respect of `business ethics'. The NHS reforms also appear to accentuate the tensions between transparent public accountability in NHS management and incentives not to publicize certain types of information. Recent codification of NHS `business ethics' can be understood as an attempt to buttress the public service ethos against the increased moral strains of a quasi-market.