Brian Hardy

Interagency and interprofessional collaboration in community care: the interdependence of structures and values

This paper considers the problems of interagency and interprofessional collaboration in community care in Great Britain from the combined perspectives of UK and US researchers. The research team drew on empirical and theoretical literature from both countries to construct a framework for analysing inter- and intra-organisational theories of joint working. This analysis, supplemented and supported by local case studies conducted by the researchers, generates a framework recommendation against which the governments initiatives for partnership working in the NHS plan 2000 and subsequently can be critically reviewed. In particular, at a time when structural integration--via Care Trusts--is being seriously considered, they highlight the vital importance of integrated systems of goal setting, authority and multidisciplinary service delivery rather than a narrow focus on structural integration alone.

Commissioning for Quality: Ten Years of Social Care Markets in England

The introduction of social care markets was one of the main planks of the Conservative governments community care reforms of 1990. The Labour government, whilst emphasising collaboration rather than competition, has not sought to reverse this policy. What have been the consequences? We discuss a decade of market-related change under five heads: purchasers, providers, commissioning, care planning and delivery, and users and carers. There have been quite substantial changes effected by social care markets in each domain, in turn generating a number of pertinent questions for the future success of social care policy in England. One is the very suitability of market-like arrangements in social care. Another is whether transaction costs are too high. More generally, are social care markets structured in a way that will generate the efficiency improvements that successive governments expect of them? Fourth, to what extent will price competition damage quality of care? Finally, will commissioning arrangements mature so as to achieve a better balance between competitive and collaborative modes of working?

Inter-agency services in England and The Netherlands: A comparative study of integrated care development and delivery

In England and the Netherlands there is much comparable experience in developing and delivering integrated services, provided by different health care agencies to people with multiple care demands. The achievement of integrated care provision in such cases appears to be very difficult and laborious in both countries. This article may be considered a first step in exploring the reasons for this and in developing a framework that is not context specific, as a contribution to a more generally applicable analysis of obstacles to integration and the means for overcoming them. After analysing the English and Dutch health and social care systems and their development in recent decades, we conclude that basically there are clear system similarities which are hindering the integration of services, for instance the predominant complexity of the system with a lot of stakeholders having different roles, tasks, interests and power positions. We have identified common mechanisms that play a dominant role in both systems; not only the social, economic and political context, but also the local context, the legal context and funding streams. Other relevant factors are the procedural and structural arrangements at different system levels and the collaborative culture and tradition. The way these mechanisms work in practice, however, is different for England and the Netherlands, due to system differences. In the Netherlands for instance there is a clear emphasis on bargaining in the context of non-hierarchical structured networks, whilst in England hierarchies and the interplay between hierarchies, markets and networks play a more dominant role. In spite of the differences and problems in both countries we have found a similar recognition of interdependence and willingness to pursue integration of services for multi-problem patients.

The influence of institutions and culture on health policies: different approaches to integrated care in England and The Netherlands

The concept of integrated care has assumed growing importance on the policy agendas both in England and The Netherlands and elsewhere. It is characterized as health and health care-related social care needed by patients with multi-faceted needs. This article compares policy approaches to integrated care in England and The Netherlands. Differing political strategies and conditions for integrated care correspond to the dissimilarities in the institutional structure and culture of their health care systems. Health care systems are understood as specific national and historical configurations. We review the last decade’s relevant policy processes, using the concepts of hierarchy, market and network. The state health care system in England relies mainly on hierarchical steering, thus creating tight network structures for integrated care on the local level. The Netherlands, with its health care system in a public-private mix, has set incentives for voluntary, loosely coupled and partly market-driven cooperation on the local level. Implications for success or failure are mixed in both configurations. Policy recommendations have to be tailored to each systems’ characteristics.

Joint Management in Community Care

Government ministers have stressed that inter‐agency co‐ordination will be crucial to the success of their community care proposals. Yet the history of collaboration between health and local authorities has been one of limited achievements. Notwithstanding this general record there are a growing number of examples of apparently successful co‐ordination; moreover, amongst these are projects involving joint management, which is inter‐agency co‐ordination at its most complex. This article reports on a detailed study of five such projects, across a range of client groups, undertaken on behalf of the Department of Health. We found that the essence of such schemes is their fragility and vulnerability to a range of organisational pressures. We concluded that these pressures are sufficient to threaten the survival of newly established projects unless managers address certain key imperatives which we outline here.

Localization and Partnership in the ‘New National Health Service': England and Scotland Compared

This article examines some important and interesting differences in the designs of the ‘New NHS’ in England and Scotland in respect of two common guiding imperatives – localization and partnership. In examining the view of key local stakeholders faced with introducing the changes, we contrast the generally more flexible and less prescriptive approach in Scotland. In England there was, initially, a raft of guidance from the centre: in Scotland, by contrast, there was virtually none. In England the prime bases for localization will be PCGs and PCTs: in Scotland they will be Local Health Care Co-operatives (LHCCs). The latter, like the English PCGs, are to be GP-led; but unlike PCGs, membership is voluntary. Underlying such redesign of the organizational architecture are some important changes in cultures and modes of governance. In particular, we note the rhetoric of a shift, at macro-level, from hierarchies and quasi-markets to networks and the perceived reality of a micro-level shift from individualism to collegiality amongst GPs.

Transferring care: Can financial incentives work?

Local and health authorities have never found it easy to work together. The ‘care in the community’ policy for the elderly, the mentally ill and the mentally handicapped obliges them to do this. A comparison of three English regional health authorities and the Welsh Office suggests that England has much to learn from its smaller neighbour.