Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice

Background: Independent contractor status of NHS general dental practitioners (GDPs) and general medical practitioners (GMPs) has meant that both groups have commercial as well as professional identities. Their relationship with the state is governed by a NHS contract, the terms of which have been the focus of much negotiation and struggle in recent years. Previous study of dental contracting has taken a classical economics perspective, viewing practitioners’ behaviour as a fully rational search for contract loopholes. We apply institutional theory to this context for the first time, where individuals’ behaviour is understood as being influenced by wider institutional forces such as growing consumer demands, commercial pressures and challenges to medical professionalism. Practitioners hold values and beliefs, and carry out routines and practices which are consistent with the field’s institutional logics. By identifying institutional logics in the dental practice organisational field, we expose where tensions exist, helping to explain why contracting appears as a continual cycle of reform and resistance. Aims: To identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services, using a comparison with medical practice to highlight factors which are particular to NHS dental practice. Methods: Following a systematic review of health-care contracting theory and interviews with stakeholders, we undertook case studies of 16 dental and six medical practices. Case study data collection involved interviews, observation and documentary evidence; 120 interviews were undertaken in all. We tested and refined our findings using a questionnaire to GDPs and further interviews with commissioners. Results: We found that, for all three sets of actors (GDPs, GMPs, commissioners), multiple logics exist. These were interacting and sometimes in competition. We found an emergent logic of population health managerialism in dental practice, which is less compatible than the other dental practice logics of ownership responsibility, professional clinical values and entrepreneurialism. This was in contrast to medical practice, where we found a more ready acceptance of external accountability and notions of the delivery of ‘cost-effective’ care. Our quantitative work enabled us to refine and test our conceptualisations of dental practice logics. We identified that population health managerialism comprised both a logic of managerialism and a public goods logic, and that practitioners might be resistant to one and not the other. We also linked individual practitioners’ behaviour to wider institutional forces by showing that logics were predictive of responses to NHS dental contracts at the dental chair-side (the micro level), as well as predictive of approaches to wider contractual relationships with commissioners (the macro level) . Conclusions: Responses to contracts can be shaped by environmental forces and not just determined at the level of the individual. In NHS medical practice, goals are more closely aligned with commissioning goals than in general dental practice. The optimal contractual agreement between GDPs and commissioners, therefore, will be one which aims at the ‘satisfactory’ rather than the ‘ideal’; and a ‘successful’ NHS dental contract is likely to be one where neither party promotes its self-interest above the other. Future work on opportunism in health care should widen its focus beyond the self-interest of providers and look at the contribution of contextual factors such as the relationship between the government and professional bodies, the role of the media, and providers’ social and professional networks. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Logics of Action, Globalization, and Employment Relations Change in China, India, Malaysia, and the Philippines

A logic of action framework is developed in order to conceptualize and understand the impact of globalization on employment relations, as well as to predict the future trajectory of employment relations. The argument is that the interplay between three different logics of action, i.e., the logic of competition, the logic of industrial peace, and the logic of employment-income protection determines the employment relations pattern in any given nation. The strengths of the logics themselves are determined by five often related factors, i.e., economic development strategy, the intensity of globalization, union strength, labor market features and government responsiveness to workers. Drawing on extensive field research on national policies and workplace practices in India, China, the Philippines and Malaysia, we show support for our framework. We find that ER patterns are reflect different combinations of logic strengths, that globalization\u27s impact on employment relations is not only complex, but contingent, and we suggest that long term convergence in employment relations is unlikely given variations in the combinations of logic strengths in different countries, and changes in logic strengths over time

Coalgebraic completeness-via-canonicity for distributive substructural logics

We prove strong completeness of a range of substructural logics with respect to a natural poset-based relational semantics using a coalgebraic version of completeness-via-canonicity. By formalizing the problem in the language of coalgebraic logics, we develop a modular theory which covers a wide variety of different logics under a single framework, and lends itself to further extensions. Moreover, we believe that the coalgebraic framework provides a systematic and principled way to study the relationship between resource models on the semantics side, and substructural logics on the syntactic side.Comment: 36 page

Hybrid laws: constitutionalizing private governance networks

s.a.: Das Recht hybrider Netzwerke. Zeitschrift für das gesamte Handelsrecht und Wirtschaftsrecht 165, 2001, 550-575.. Italienische Fassung: Diritti ibridi: la costituzionalizzazione delle reti private di governance. In: Gunther Teubner, Costituzionalismo societario. Armando, Roma 2004 (im Erscheinen)

Uniform interpolation and coherence

A variety V is said to be coherent if any finitely generated subalgebra of a finitely presented member of V is finitely presented. It is shown here that V is coherent if and only if it satisfies a restricted form of uniform deductive interpolation: that is, any compact congruence on a finitely generated free algebra of V restricted to a free algebra over a subset of the generators is again compact. A general criterion is obtained for establishing failures of coherence, and hence also of uniform deductive interpolation. This criterion is then used in conjunction with properties of canonical extensions to prove that coherence and uniform deductive interpolation fail for certain varieties of Boolean algebras with operators (in particular, algebras of modal logic K and its standard non-transitive extensions), double-Heyting algebras, residuated lattices, and lattices