Elke Heins

A Review of the Evidence of Third Sector Performance and Its Relevance for a Universal Comprehensive Health System

UK policy promotes third sector organisations as providers of NHS funded health and social care. We examine the evidence for this policy through a systematic literature review. Our results highlight several problems of studies comparing non-profits with other provider forms, questioning their usefulness for drawing lessons outside the place of study. Most studies deem contextual factors and the regulatory framework in which providers operate as much more important than ownership form. We conclude that the literature does not support the policy of a larger role for the third sector in healthcare, let alone a switch to a market-based system.

The commercialisation of GP services: a survey of APMS contracts and new GP ownership

BACKGROUND Alternative provider of medical services (APMS) legislation enables private commercial firms to provide NHS primary care. There is no central monitoring of APMS adoption by primary care trusts (PCTs), the new providers, or market competition. AIM The aims were to: examine APMS contract data on bidders and providers, patient numbers, contract value, duration, and services; present a typology of primary care providers; establish the extent of competition; and identify which commercial providers have entered the English primary care market. DESIGN OF STUDY Cross-sectional study. SETTING All PCTs in England. METHOD A survey was carried out in March 2008 gathering information on the number of APMS contracts, their value and duration, patient numbers, the successful tender, and other bidders. RESULTS A total of 141 out of 152 PCTs provided information on 71 APMS contracts that had been awarded and 66 contracts that were out to tender. Of those contracts awarded, 36 went to 14 different commercial companies, 28 to independent GP contractors, seven to social enterprises, and two to a PCT-managed service; one contract is shared by three different provider types. In more than half of the responses information on competition was not disclosed. In a fifth of those contracts awarded to the commercial sector, for which there is information on other bidders, there was no competition. Contracts varied widely, covering from one to several hundred thousand patients, with a value of pound6000-12 million, and lasting from 1 year to being open-ended. Most contracts offered standard, essential, additional, and enhanced services; only a few were for specialist services. CONCLUSION The lack of data on cost, patient services, and staff makes it impossible to evaluate value for money or quality, and the absence of competition is a further concern. There needs to be a proper evaluation of the APMS policy from the perspective of value for money and quality of care, as well as patient access and coverage.

The Sovereign Debt Crisis, the EU and Welfare State Reform

In this concluding chapter the key findings of the volume are summarized and an outlook on the prospective development of the social dimension in the Eurozone are given. As the various country case studies in this book have shown, the EU has been unprecedentedly involved in national welfare state affairs, particularly in those countries that had to seek official financial assistance from the European Union (EU) and International Monetary Fund (IMF) as well as in the wider Eurozone. Nevertheless, the contributors to this book pointed to important differences in the level of intrusiveness depending on country context or policy area. Regarding welfare societies in European more widely following the Great Recession, it can be concluded that all have become less secure and more unequal. Looking at pensions, economic stabilization has been reached for the time being, but adequacy remains a challenge. Regarding unemployment benefits and labour market policies we find that these have become characterised by less generosity and more flexibility. In the context of a still fragile economic recovery and a rejection of the prescribed austerity measures by many electorates in the crisis countries, the European Commission now emphasises more upfront that social fairness considerations have to be taken into account when implementing measures that aim at stabilizing the European economies. Important debates have been initiated recently as to how not only to make the Eurozone more crisis-resilient but also to strengthen the political union and the social dimension.

The role of wage bargaining partners in public sector reform : The case of primary care contracts

We take the 2004 contract between British general practitioners and the government as an example of dilemmas that confront all European health systems. The contract allowed doctors to withdraw from out-of-hours coverage, but enabled commercial providers to enter the primary care market. Our research suggests that the doctors underestimated the threat of commercialization posed by these new contracts. Only after the consequences of the reform became clear they took policy positions against the commercialization which was facilitated by the contract they had agreed. This case is an illustrative example of the way that wage bargaining partners in the health service become involved in the structural maintenance of the system as well as the pay and conditions of their members, with possible trade-offs between the two.

Introduction: Is the European Union More Involved in Welfare State Reform Following the Sovereign Debt Crisis?

This book analyses how the European Union (EU) has affected welfare state reforms in the Member States most severely hit by the crisis. This introductory chapter contextualizes our contribution to the vibrant literature that has been published since the special issue on which this book is based has been in press. We further remind the reader of the severe crisis context in which the EU altered existing tools and developed new ones in the governance of the Economic and Monetary Union (EMU) and of social policy. The findings of this book show that the nature of EU intervention into domestic welfare states has changed, with an enhanced focus on fiscal consolidation, increased surveillance and enforcement of EU measures. Overall, this represents a radical alteration of EU integration, whereby the EU is involved in domestic affairs to an unprecedented degree, particularly with regard to national budgets of which welfare state spending is an important component. Since these changes are highly institutionalized, particularly with regard to balanced budgets, it is necessary that the EU encourages social investment much more than it does presently.