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Purpose Neo-liberal “reform” has in many countries shifted services across the boundary between the public and private sector. This policy re-opens the question of what structural and managerial differences, if any, differences of ownership make to healthcare providers. The purpose of this paper is to examine the connections between ownership, organisational structure and managerial regime within an elaboration of Donabedian’s reasoning about organisational structures. Using new data from England, it considers: how do the internal managerial regimes of differently owned healthcare providers differ, or not? In what respects did any such differences arise from differences in ownership or for other reasons? Design/methodology/approach An observational systematic qualitative comparison of differently owned providers was the strongest feasible research design. The authors systematically compared a maximum variety (by ownership) sample of community health services; out-of-hours primary care; and hospital planned orthopaedics and ophthalmology providers (n=12 cases). The framework of comparison was the ownership theory mentioned above. Findings The connection between ownership (on the one hand) and organisation structures and managerial regimes (on the other) differed at different organisational levels. Top-level governance structures diverged by organisational ownership and objectives among the case-study organisations. All the case-study organisations irrespective of ownership had hierarchical, bureaucratic structures and managerial regimes for coordinating everyday service production, but to differing extents. In doctor-owned organisations, the doctors’, but not other occupations’, work was controlled and coordinated in a more-or-less democratic, self-governing ways. Research limitations/implications This study was empirically limited to just one sector in one country, although within that sector the case-study organisations were typical of their kinds. It focussed on formal structures, omitting to varying extents other technologies of power and the differences in care processes and patient experiences within differently owned organisations. Practical implications Type of ownership does appear, overall, to make a difference to at least some important aspects of an organisation’s governance structures and managerial regime. For the broader field of health organisational research, these findings highlight the importance of the owners’ agency in explaining organisational change. The findings also call into question the practice of copying managerial techniques (and “fads”) across the public–private boundary. Originality/value Ownership does make important differences to healthcare providers’ top-level governance structures and accountabilities and to work coordination activity, but with different patterns at different organisational levels. These findings have implications for understanding the legitimacy, governance and accountability of healthcare organisations, the distribution and use power within them, and system-wide policy interventions, for instance to improve care coordination and for the correspondingly required foci of healthcare organisational research.

Objectives To establish how quality indicators used in English community nursing are selected and applied, and their perceived usefulness to service users, commissioners and service providers. Methods A qualitative multi-site case study was conducted with five commissioning organizations and their service providers. Participants included commissioners, provider organization managers, nurses and service users. Results Indicator selection and application often entail complex processes influenced by wider health system and cross-organizational factors. All participants felt that current indicators, while useful for accountability and management purposes, fail to reflect the true quality of community nursing care and may sometimes indirectly compromise care. Conclusions Valuable resources may be better used for comprehensive system redesign, to ensure that patient, carer and nurse priorities are given equivalence with those of other stakeholders.

Policy driven change is challenging, with a significant gap between theory and practice. A key tension in enacting such change is achieving a balance between bottom-up development of local, context-specific approaches, and top-down, centrally determined policy solutions and their mutual sequencing. Ideal type models of the policy-making process envisage a rational ordered approach, driven by evidence and accompanied by ongoing evaluation of outcomes (Parsons, 1995, p77); however, the reality is far more complex. We examine the implementation and early operation of the New Care Models (NCM) Vanguard programme in England, using Matland’s (1995) ambiguity-conflict model, to explore the aims and expectations of the programme. We consider the relationship between top-down and bottom-up approaches to policy development and draw attention to the pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid learning, scale and spread. We suggest that future programmes for large-scale policy implementation initiatives could be crafted differently to take account of the environment of implementation and render ambitions more realistic. Rather than aiming to create a set of definite products and templates, it may be that a set of principles for design and implementation should be developed and spread.

The aim of this book is to bring together in one volume the most important research which the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) has undertaken during the period 2011 to 2018. PRUComm is a multicentre research unit based at the London School of Hygiene & Tropical Medicine, the University of Manchester and the University of Kent. PRUComm is funded by the Policy Research Programme of the English Department of Health and Social Care from 2011 onwards to provide evidence to the DHSC to inform the development of policy on commissioning and the healthcare system. The analytical work supports understanding of how NHS commissioning operates and how it can improve services and access, increase effectiveness and respond better to patient and population needs. The structural changes introduced by the Health and Social Care Act 2012 pursuant to the twin policies of increasing clinical involvement in commissioning and accelerating market forces have had large effects on the practice of commissioning across the NHS. There has been a great increase in the complexity of health system governance. The number of bodies undertaking commissioning has increased and there has also been a proliferation of other NHS organisations required to regulate the complex system. The effect of this increase in complexity in the governance of the NHS has been wide-ranging. As a result, local autonomy is severely limited and the original policy aspirations to deliver freedom from government control and greater accountability to patients and greater democratic legitimacy have not been realised to any significant degree. In addition, the fragmentation of commissioning roles has been damaging to the planning and delivery of services which are subject to several commissioning regimes. Not only is there evidence of deterioration in patient outcomes, but the research has also demonstrated that significant effort, and thus opportunity cost, is required from commissioners to ‘knit back together’ pre-existing systems of service planning and delivery. The issue of accountability of commissioners is closely related to the problem of increased complexity of commissioning and system governance. Local Clinical Commissioning Groups are stated to be membership organisations whose primary accountability is internally to their GP members. But in fact the strongest form of accountability would seem to be their hierarchical upwards accountability to NHS England, the national body running the NHS. In addition, the delegation of responsibility for commissioning of primary care to CCGs presents a risk that groups of GPs will commission themselves to provide services, creating a structural conflict of interest, which may undermine their public stewardship role in respect of commissioning budgets. The complex regulatory structures of the NHS required to police the marketised system introduced by the HSCA 2012 have effects on the efficiency of the system as a whole. Inappropriate use of market institutional structures, as opposed to integrated hierarchies, can decrease overall efficiency by increasing costs of undertaking transactions. A further effect of the changes to commissioning introduced by the HSCA 2012 has been on clinicians in primary care. Despite the fact that the research has indicated that they can make a useful contribution to commissioning by CCGs, the workload associated with such involvement is substantial, with a potentially damaging effect on the working lives of GPs, who are already under stress from excessive demands on their time. This makes the sustainability of the model of GP involvement in CCGs dubious. Despite the problems associated with the HSCA 2012, we argue that there will always be a role for planning, and thus a degree of commissioning in the NHS, as a publicly funded system. Strategic decisions need to be made about the allocation of public resources between different services in order to optimise population health and wellbeing. It is also necessary to monitor the performance of providers of care and make improvements where care is substandard. Thus, the core activities of commissioning are necessary whether pro-competitive quasi-market aspects of the English NHS are retained or not. But commissioning in its current form is unlikely to continue, given plans being developed at national level merge CCGs and introduce intermediate tiers of supervision.

Purpose The purpose of this paper is to investigate the perceptions of key informants on a national support programme for the development of new care models (NCM) in England (2015/2016–2017/2018). It focuses on the perceived facilitators and barriers affecting the development and implementation of the NCM programme and offers some insight into the role of national level support in enabling local integration initiatives. Design/methodology/approach A set of 29 interviews were carried out with a variety of respondents at the national level (including current and past programme leads, strategic account managers, advisors to the programme and external regulators) between October 2017 and March 2018, and analysed thematically. Findings A set of facilitative elements of the programme were identified: the development of relationships and alliances, strong local and national leadership, the availability of expert knowledge and skills, and additional funding. Challenges to success included perceived expectations from the national Vanguard programme, oversight and performance monitoring, engagement with regulators, data availability and quality, as well as timetables and timescales. Crucially, the facilitators and challenges were found to interact in dynamic and complex ways, which resulted in significant tensions and ambiguities within the support programme. Research limitations/implications While the sample was drawn from a range of different senior players and the authors ensured a diverse sample associated with the NCM support programme, it inevitably cannot be complete and there may have been valuable perspectives absent. Originality/value The paper demonstrates that the analysis of facilitators and challenges with respect to the national support of implementation of integrated care initiatives should move beyond the focus on separate influencing factors and address the tensions that the complex interplay among these factors create.

The coordination of public services is an enduring challenge and an important policy priority. One way to achieve collaboration across organizational boundaries, which is being considered in public services such as the English National Health Service (NHS), is through the adoption of alliance contracting, prime provider contracting and outcome-based contracting. This article reviews the cross-sectoral literature concerning the characteristics of these new contractual models, how they function, their impact, and their relation to public sector governance objectives. These new contractual forms are characterized as models which, in line with the New Public Management (NPM)/post-NPM agenda, seek to incentivize providers through the transfer of risk from the commissioners to the providers of services. Key findings are that the models are likely to incur high transaction costs relating to the negotiation and specification of outcomes and rely heavily on the relational aspects of contracting. There is also found to be a lack of convincing cross-sectoral evidence of the impact of the models, particularly in relation to improving coordination across organizations. The article questions the reconciliation of the use of these new contractual models in settings such as the English NHS with the requirements of public sector governance for transparency and accountability. The models serve to highlight the problems inherent in the NPM/post-NPM agenda of the transfer of risk away from commissioners of services in terms of transparency and accountability.

Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring ‘practice languages’ is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor ‘care pathway’ is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as ‘designing a pathway’ may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use.

The optimal balance between central governmental authority and the degree of autonomy of local public bodies is an enduring issue in public policy. The UK National Health Service is no exception, with NHS history, in part at least, a history of repeated cycles of centralisation and decentralisation of decision-making power. Most recently, a significant reorganisation of the NHS in 2012–13 was built around the creation of new and supposedly more autonomous commissioning organisations (Clinical Commissioning Groups – CCGs). Using Bossert's (1998) concept of ‘decision space’, we explored the experiences of local commissioners as they took on their new responsibilities. We interviewed commissioning staff from all of the CCGs in two regional health care ‘economies’, exploring their perceptions of autonomy and their experiences over time. We found significant early enthusiasm for, and perceptions of, increased autonomy tempered in the vertical dimension by increasingly onerous and prescriptive monitoring regimes, and in the horizontal dimension by the proliferation of overlapping networks, inter-organisational groups and relationships. We propose that, whatever the balance between central and local control that is adopted, complex public services require some sort of meso-level oversight from organisations able to ‘hold the ring’ between competing interests and to take a regional view of the needs of the local health system. This suggests that local organisational autonomy in such services will always be constrained.

The authors investigated how the formal national provisions for pricing in the National Health Service (which are a form of prospective payment, known as ‘Payment by Results’) are operationalized at local level. Transactions costs theory and existing evidence predict that actual practice often does not comply with contractual rules. A national study of pricing between 2011 and 2015 confirms this and indicates that such payment systems may not be appropriate to address the current financial and organizational challenges facing the NHS. As the NHS struggles radically to reconfigure services, it is necessary to reconsider the appropriateness of a wider range of pricing mechanisms to facilitate moving care out of hospitals.

A challenge facing health systems such as the English National Health Service (NHS), which operate in a context of diversity of provision and scarcity of financial resources, is how organisations engaged in the provision of services can be encouraged to adopt collective resource utilisation strategies to ensure limited resources are utilised in the interests of service users and, in the case of tax funded services, the general public. In this paper the authors apply Elinor Ostrom's work concerning communities' self-governance of common pool resources to the development of collective approaches to the utilisation of resources for the provision of health services. Focusing on the establishment of Sustainability and Transformation Partnerships (STPs) in the English NHS, and drawing on interviews with senior managers in English NHS purchaser and provider organisations, we use Ostrom's work as a frame to analyse STPs, as vehicles to agree and enact shared rules governing the allocation of financial resources, and the role of the state in relation to the development of this collective governance. While there was an unwillingness to use STPs to agree collective rules for resource allocation, we found that local actors were discussing and agreeing collective approaches regarding how resources should be utilised to deliver health services in order to make best use of scarce resources. State influence on the development of collective approaches to resource allocation through the STP was viewed by some as coercive, but also provided a necessary function to ensure accountability. Our analysis suggests Ostrom's notion of resource 'appropriation' should be extended to capture the nuances of resource utilisation in complex production chains, such as those involved in the delivery of health services where the extraction of funds is not an end in itself, but where the value of resources depends on how they are utilised.

Meta-governance involves orchestrating the ‘rules of the game’ in public management. Arm’s-length bodies are particularly important vehicles for this. We consider the case of an arm’s-length body (NHS England) created to oversee the English NHS’ day-to-day operation, and remove ‘political interference’. Although mandated by the Department of Health it has increasingly operated as policy-maker, developing policies in tension with existing legislation, while Ministers have faded from public-facing accounts of service operation. This suggests NHS England operates as a meta-governor, insulating government whilst pursuing its own agenda, and raises crucial questions about governmental accountability whilst simultaneously making answers harder to obtain.

In the context of welfare delivery, hybrid organisations mix public and ‘new’ market, social, and professional types of mechanisms and rationales. This paper contributes to our understanding of accountability within hybrid organisations by highlighting how accountability obligations can become hybrid, simultaneously formal and informal. Instead of seeing accountability as hybrid only in the sense of the co‐existence of types of organisational mechanisms and structures (i.e., the prevalence of both state and market types), we examine accountability arrangements governing a hybrid model — primary care commissioning in England — and interrogate the relationships between accountability actors and their accountability forums. We conceptualise ‘hybrid accountability obligations’ as a state whereby the nature of obligation underpinning accountability relationships is both formal‐informal and vertical‐horizontal concurrently. The paper concludes by highlighting the consequences of this kind of hybridity accountability, namely how it extended discretion from welfare delivery to the domain of welfare governance.

Since 2008, health policy in England has been focusing increasingly on improving quality in healthcare services. To ensure quality improvements in community nursing, providers are required to meet several quality targets, including an incentive scheme known as Commissioning for Quality and Innovation (CQUIN). This paper reports on a study of how financial incentives are used in district nursing, an area of care which is particularly difficult to measure and monitor.

Among the homiletic corpora of late antiquity the 125 surviving homilies of Severus, patriarch of Antioch (512–518), provide us with a rich lode of works on martyrs. This is not surprising, given that Antioch was second only to Rome in the number of martyrs and saints it venerated. Previously I have examined Severus’ treatment of the deaths of two local martyrs, Barlaam/Barlaha and Romanus (in Martyrdom and Persecution in Late Antique Christianity. Festschrift Boudewijn Dehandschutter, ed. J. Leemans, Leuven – Paris – Walpole, MA, 2010, pp. 1–14) and of four martyrs foreign to Antioch, Drosis/Drosina, Julian, Dometius, and Leontius ( Journal of the Australian Early Medieval Association, 5 [2009], pp. 9–20), an examination that proved the quality of the sources which the patriarch used in his preaching. In this paper I intend to carry the discussion further by concentrating on Severus’ treatment of the death of St Babylas in one homily and two hymns, particularly in relation to the treatment accorded to the martyr in John Chrysostom, in order to situate Severus’ homily in the martyrial homiletic tradition and to trace the history of the veneration of this saint in the city of Antioch.

In England, ‘policy experiments’ are largely synonymous with the use of randomized controlled trials (RCTs) to test whether one policy ‘works’ better than another. While advocacy of the use of RCTs in public policy presents this as relatively straightforward, even common sense, the reality is different, as shown through analysis of three high profile policy pilots and their evaluations undertaken in health and social care in England in the mid/late 2000s. The RCTs were expected to confirm the direction of policy by resolving any remaining uncertainty about the effectiveness of the chosen path and their existence was used largely as instruments of persuasion. The findings from the analysis of the three pilots confirm the continuing relevance of Campbell’s 1969 insight that governments struggle to experiment in the scientific sense and explain the limited effect of these policy experiments on policy decisions.

Objective: The Health and Social Care Act 2012(‘HSCA 2012’) introduced a new, statutory, form ofregulation of competition into the National HealthService (NHS), while at the same time recognising thatcooperation was necessary. NHS England’s policydocument, The Five Year Forward View (‘5YFV’) of2014 placed less emphasis on competition withoutaltering the legislation. We explored howcommissioners and providers understand the complexregulatory framework, and how they behave in relationto competition and cooperation.Design: We carried out detailed case studies in fourclinical commissioning groups, using interviews anddocumentary analysis to explore the commissioners’and providers’ understanding and experience ofcompetition and cooperation.Setting/participants: We conducted 42 interviewswith senior managers in commissioning organisationsand senior managers in NHS and independent providerorganisations (acute and community services).Results: Neither commissioners nor providers fullyunderstand the regulatory regime in respect ofcompetition in the NHS, and have not found that theregulatory authorities have provided adequateguidance. Despite the HSCA 2012 promotingcompetition, commissioners chose mainly to usecollaborative strategies to effect major servicereconfigurations, which is endorsed as a suitableapproach by providers. Nevertheless, commissionersare using competitive tendering in respect of moreperipheral services in order to improve quality of careand value for money.Conclusions: Commissioners regard the use ofcompetition and cooperation as appropriate in the NHScurrently, although collaborative strategies appear morehelpful in respect of large-scale changes. However, thecurrent regulatory framework contained in the HSCA2012, particularly since the publication of the 5YFV, isnot clear. Better guidance should be issued by theregulatory authorities.

This paper explores how 'place' is conceptualised and mobilized in health policy and considers the implications of this. Using the on-going spatial reorganizing of the English NHS as an exemplar, we draw upon relational geographies of place for illumination. We focus on the introduction of 'Sustainability and Transformation Plans' (STPs): positioned to support improvements in care and relieve financial pressures within the health and social care system. STP implementation requires collaboration between organizations within 44 bounded territories that must reach 'local' consensus about service redesign under conditions of unprecedented financial constraint. Emphasising the continued influence of previous reorganizations, we argue that such spatialized practices elude neat containment within coherent territorial geographies. Rather than a technical process financially and spatially 'fixing' health and care systems, STPs exemplify post-politics-closing down the political dimensions of policy-making by associating 'place' with 'local' empowerment to undertake highly resource-constrained management of health systems, distancing responsibility from national political processes. Relational understandings of place thus provide value in understanding health policies and systems, and help to identify where and how STPs might experience difficulties.

A policy of separating all NHS community health services (CHS) from commissioning organisations (then primary care trusts) was launched in 2008. Some CHS were to become foundation trusts (FTs—in this case, CFTs). FTs are NHS organizations with greater autonomy from the centre, able to retain any surpluses, which are thought to be able to improve efficiency and quality of services. Those CHS not destined to become CFTs were to be merged with NHS mental health and/or hospital services, or to be ‘spun out’ of the NHS to become independent not-for-profit organisations. We observed the changes made during the preparatory period, and the expectations of the effects of FT status of the managers of CHS and their NHS commissioners, together with those CHS not on the CFT pathway. We found that all CHS in the study were becoming more business-like, and starting to improve service delivery and productivity, irrespective of whether they were destined to become CFTs. Although increased autonomy was appreciated, most CHS wanted to stay within the NHS. Some managers were concerned they would lose their autonomy when merging with other NHS services. The changes and uncertainty about organisational policy for CHS have been disruptive and time consuming.

Personal or individual budgets for purchasing health and social care are intended to offer more choice, control and flexibility to service users when compared with agency-directed care. They are becoming an increasingly common feature in high-income countries for purchasing personal care that often lies on the border line between health and social care. In England, they have recently been introduced explicitly for the purchasing of health care. There are some key motivations behind their introduction: they are expected to give individuals more choice about care they receive; to expand options for care; to improve outcomes; and to reduce expenditure. This paper draws from a review of the international evidence on personal budgets which identified: descriptive detail on personal budget schemes in 11 OECD countries to examine their key features and implementation processes; empirical evidence on the experiences of, and outcomes for, people using these schemes, and; empirical evidence regarding the impact of the schemes on the healthcare system, particularly with regards to resources. The paper examines the motivating factors behind personal budget schemes in light of this evidence. It concludes that there is little in the evidence to suggest that international governments’ expectations for personal budget programmes are well-founded. The assumptions that they improve choice, and that more choice will in turn lead to greater autonomy and then improved outcomes at lower cost, are actually far more complex and generally unsupported by evidence.

Contracting in the public sector is designed to enhance the accountability of service providers to their funders. The idea is that quality is improved by the use of service specifications, monitoring of performance and imposition of contractual sanctions. Socio-legal and economic theories of contract indicate that it will be difficult to make and enforce contracts to achieve this. The results of a study of National Health Services contracting in England and Wales are reported. We conclude that contracts alone are not sufficient to improve accountability – collibration of various regulatory measures (including more hierarchical mechanisms such as performance targets) is required.

The edition of Eleni S. Chatzoglou-Balta is based on two manuscripts: the twelfth-century Scorialensis gr. 527 (W.II.10), fol. 47v-50v, and the 14–15thcentury Vaticanus gr. 1192, fol. 74v-79. To judge from the frequency of citation in the homily, possible readings for the day are Psalm 109 (110):1, Dan 7:10–14, and Acts 1:9–11. There is no unambiguous reference to readings which the congregation have heard or sung.

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK-wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro-level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.

In addition to introducing markets and market-like structures into public services, New Labour wished to promote the involvement of users and the public in decision-making in other ways than as individual consumers. One way was to involve the public in the governance of organizations. This could be done by removing public services from state control, and transferring them to mutual ownership; or by increasing public involvement in the governance of public bodies. NHS foundation trusts (FTs) were presented as mutuals. Our study shows FTs are not mutuals, as they continue to be owned by the state. Moreover, staff of FTs were generally not engaging with the new governance structures. In general, there was mixed experience of the new structures enabling governors to increase accountability of the hospitals to the public. On the other hand, having a membership did enhance the legitimacy of FTs, as opposed to other NHS organizations. The findings of the study are of current interest as the coalition government is continuing with the policy of FTs, and also encouraging mutuals and other forms of public involvement.

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.

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. Introduction: policy of increasing diversity of providers in the NHS Recent history of the NHS The English National Health Service (NHS) was established in 1948. It is a tax funded healthcare system, free at the point of use for all patients. It is a

Purpose – The purpose of this paper is to explore government efforts to enhance the autonomy of community health services (CHS) in England through the creation of Foundation Trusts status. It considers why some CHS elected to become nascent Community Foundation Trusts (CFTs) while others had not and what advantages they thought increased levels of autonomy offered. Design/methodology/approach – Data are drawn from the evaluation of the Department of Health’s CFT pilot programme. Participants were purposively selected from pilot sites, as well as from comparator non-pilot organisations. A total of 44 staff from 14 organisations were interviewed. Findings – The data reveals that regardless of the different pathways that organisations were on, they all shared the same goal, a desire for greater autonomy, but specifically within the NHS. Additionally, irrespective of their organisational form most organisations were considering an almost identical set of initiatives as a means to improve service delivery and productivity. Research limitations/implications – Despite the expectations of policy makers no CFTs were established during the course of the study, so it is not possible to find out what the effect of such changes were. Nevertheless, the authors were able to investigate the attitudes of all the providers of CHS to the plans to increase their managerial autonomy, whether simply by separating from PCTs or by becoming CFTs. Originality/value – As no CFTs have yet been formed, this study provides the only evidence to date about increasing autonomy for CHS in England.

Objectives There is a need to develop a payment system for services for children with mental health problems that allows more targeted commissioning based on fairness and need. This is currently constrained by lack of clinical consensus on the best way forward, wide variation in practice, and lack of data about activity and outcomes. In the context of a national initiative in England our aim was to develop a basis for an improved payment system. Methods Three inter-related studies: a qualitative consultation with child and adolescent mental health services (CAMHS) stakeholders on what the key principles for establishing a payment system should be, via online survey ( n = 180) and two participatory workshops ( n = 91); review of relevant national clinical guidelines ( n = 15); and a quantitative study of the relationship between disorders and resource use ( n = 1774 children from 23 teams). Results CAMHS stakeholders stressed the need for a broader definition of need than only diagnosis, including the measurement of indirect service activities and appropriate outcome measurement. National clinical guidance suggested key aspects of best practice for care packages but did not include consideration of contextual factors such as complexity. Modelling data on cases found that problem type and degree of impairment independently predicted resource use, alongside evidence for substantial service variation in the allocation of resources for similar problems. Conclusions A framework for an episode-based payment system for CAMHS should include consideration of: complexity and indirect service activities; evidence-based care packages; different needs in terms of impairment and symptoms; and outcome measurement as a core component.

Part I. Introducing Early Christian Letters: 1. Continuities and changes in the practice of letter-collecting from Cicero to late antiquity Bronwen Neil 2. Rationales for episcopal letter collections in late antiquity Pauline Allen Part II. Collecting New Testament and Early Monastic Letters: 3. The Pauline letters as community documents Ian J. Elmer 4. 2 Corinthians and possible material evidence for composite letters in antiquity Brent Nongbri 5. The letter collections of Anthony and Ammonas: shaping a community Samuel Rubenson 6. From letter to letter collection: monastic epistolography in late antique Egypt Malcolm Choat Part III. Collecting Early Bishops' Letters: 7. Letters of Ambrose of Milan (374-97), Books I-IX J. H. W. G. Liebeschuetz 8. The letters of Basil of Caesarea and the role of letter collections in their transmission Anna Silvas 9. The ins and outs of the Chrysostom letter collection: new ways of looking at a limited corpus Wendy Mayer 10. The letters of Theodoret of Cyrrhus: personal collections, multi-author archives and historical interpretation Adam M. Schor Part IV. Collecting Early Papal Letters: 11. Collectio Corbeiensis, Collectio Pithouensis and the earliest collections of papal letters Geoffrey D. Dunn 12. De profundis: the letters and archives of Pelagius I of Rome (556-61) Bronwen Neil.

The idea behind the collection of essays in this volume is to bring into focus one main aspect of the Marian cult – the invocations of Mary – across the Byzantine Empire from the fourth to the ninth century. Over the span of the five centuries with which this volume is concerned, the empire turned into a thoroughly Christian society and at the end of Iconoclasm (843) the figure of Mary is found as the intercessor of the entire empire. Why and how this development took place is a question that challenges not only the study of the Byzantine cult of Mary but the study of Byzantine society in general. This volume will be a contribution to the search for an explanation proceeding from highly variegated sources and perspectives subsumed under the title, Presbeia Theotokou. It refers to the doctrine prevailing during this transformative period, which was uninfluenced by later ideas on the significance of Mary’s part in Christ’s role as redemptor. It is agreed that regional diversity was an inherent element of the cult of Mary; the cult neither developed nor was established at the same time and in the same manner throughout the empire. The glimpses, given here, of different religious “landscapes” in Byzantine territory show first of all the cultural contexts where Mary’s intercessory role manifested itself. The selected regions – Palestine, Egypt, Constantinople, Syria, Antioch, Armenia, Durres, Rome, Italy, and North Africa – cover a great part of the territory that was under East Roman or Byzantine rule. The contributors represent expertise in early Christian, Late-Antique and Byzantine Studies. The sources – objects, texts and documents – are examined from vantage points of archaeology, art history, papyrology, sigillography, patristics, religious studies and theology.

This collection of essays by thirty of the foremost scholars in the field will for the first time present Maximus in his political, theological, and philosophical contexts. The works and life of Maximus are covered in four parts. The first section, Historical Setting, includes an update of Sherwood’s 1952 Date-List of Works of St Maximus the Confessor, and a reconstructed timeline of significant events in the life of Maximus. Overviews of the theological and political–military context of seventh-century Byzantium are also included. In the second section, Theological and Philosophical Influences, scholars consider the evidence for Plato, Aristotle, Plotinus, Origen, Pseudo-Macarius, the Cappadocians, Evagrius of Pontus, John Chrysostom, Pseudo-Dionysius, and even Augustine of Hippo as likely influences on Maximus. The third section, Works and Thought, contains chapters on Maximian cosmology, spiritual anthropology, his doctrine of divinization, ecclesiology, and eschatology. Two chapters look at the practical side of Maximian virtue ethics, in the ascetic life as described in Centuries on Love, and in his understanding of the liturgy. The final section, Reception, treats the Nachleben of Maximus’ work in medieval and modern Georgia, Russia, and Ukraine, in the Byzantine and modern Orthodox churches, and in the works and translations of John Scottus Eriugena, who brought Maximus to the West in the Carolingian era. The final chapters cover Maximus’ relevance for modern depth psychology, spiritual anthropology, and ecumenical dialogue, and his retrieval in the West in the modern era. There are detailed bibliographies for each chapter and recommendations for further reading.