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

The politics of what works in service delivery:\ud An evidence-based review

This paper examines the evidence on the forms of politics likely to promote inclusive social provisioning and enable, as opposed to constrain, improvements in service outcomes. It focuses on eight relatively successful cases of delivery in a range of country contexts and sectors (roads, agriculture, health, education) where independent evaluations demonstrate improved outcomes. The paper traces the main characteristics of the political environment for these cases, from the national political context, to the politics of sector policymaking, to the micro politics of implementation. The findings indicate that it is possible to identify connections between good performance and better outcomes at the point of delivery and the main forms of politics operating at local, sector and national levels.\ud \ud A number of common factors underpinning successful delivery emerge strongly but need to be tested through further research. In particular, the paper highlights the relationship between inclusive delivery and periods of crisis and transition;the nature of the political settlement;the types of calculations of political returns being made by political actors at all levels, and; the extent to which the state derives or seeks to enhance its legitimacy through the provision of a particular service

Institutions of sustainability in Central and Eastern European Countries

The agricultural sector in Central and Eastern Europe (CEE) is confronted by two huge problems simultaneously: transition processes and sustainability. Institutions are very important for both these problems. The purpose of this paper is to make clear that the institutional setting is very important, and to give insight into the initial situation of institutions for sustainability and transitions. For this purpose we carried out surveys in CEE with questions about government performance, institutional environment, government structures and social capital. There is strong relationship between the determinants of good government performance in general and those for good government for realizing sustainable agriculture. However, besides formal rules, the informal rules of the institutional environment and social capital are also very important for realizing of sustainable agriculture. Results of surveys show that these institutional elements and the level of social capital are different in the countries of CEE, and have to be developed. Knowledge of government performance, institutional environment and social capital is a necessary condition for developing more suitable governance structures for realizing sustainable agriculture.institutions, social capital, sustainable agriculture and Central and Eastern Europe, Institutional and Behavioral Economics,

Is acting prosocially beneficial for the credit market?

This article argues that behaving prosocially implies more transparent information during the negotiation process of a financial contract and more cooperation among the parties to respect the terms of the contract. For this reason this work considers interest rate on loans and insolvency rate functions of prosocial behaviour along with the traditional socio-economic and financial collaterals. The context of study is Italy and the analysis is developed at a cross-regional level. We collect data from the two reports on “Relatives and Safety Net” produced by the Italian Centre Bureau of Statistics (ISTAT) in 1998 and 2003 and from the reports on “Regional Economics” produced by the Bank of Italy in the same years. A two-period panel model shows two interesting outcomes. Firstly, regions with a higher proportion of prosocial individuals report lower interest rates on loans and insolvency rates. Secondly, when we include the efficiency of legal enforcement, evidence supports the idea that a more efficient legal framework can act as a more reliable transmission mechanism of institutional norms and facilitate the internalisation of social norms

Trust, Contracting, and Adaptation in Agri‐Food Hybrid Structures

The paper considers the relationship between trust and governance structure from a Transaction Cost Economics perspective. The role of trust in the coordinating decisions is variously conceptualized according to the theoretical view adopted by the scholars. The present study adopt the three‐level schema introduced by Williamson (1996) and suggest that determinants of trust may operate both at institutional and governance structure level. The analytical framework depicted maintains that trust may determine a reduction of ex post transaction cost in the adaptation of hybrid structure. As a consequence trust appears to be able to extend the range of existence of the hybrids. The empirical part of the study is dedicated to a case study which illustrates the emerging of conditional trust (Fritz et al., 2008) and the role of trust in the adaptation process.hybrid, conditional trust, adaptation, contractual relationship., Food Consumption/Nutrition/Food Safety, Food Security and Poverty, Industrial Organization, Research Methods/ Statistical Methods,

Institutions for Health Care Delivery: A Formal Exploration of What Matters to Health Workers Evidence from Rwanda

Most developing countries face important challenges regarding both the quality and quantity of health care they provide and there is a growing consensus that health workers play an important role in this. Although contemporary analysis of development emphasizes the central role of institutions, surprisingly little work looks at how institutions matter for health workers and health care delivery, which is the focus of this paper. One reason for the scarcity of work in this field is that it is unclear what the relevant theory is in this area. We carry out a formal exploratory analysis to identify both the problems and the institutional factors that offer an explanation. Using qualitative research on Rwanda, a country where health care problems are typical but where the institutional environment is dynamic enough to embody changes, we find that four institutional factors explain health worker performance and career choice. Ranked in order of ease of malleability they are: incentives, monitoring arrangements, professional norms and health workers’ intrinsic motivation. We discuss their role and the implications for future research.health workers, institutions

TOWARDS INSTITUTIONAL INFRASTRUCTURES FOR E-SCIENCE: The Scope of the Challenge

The three-fold purpose of this Report to the Joint Information Systems Committee (JISC) of the Research Councils (UK) is to: • articulate the nature and significance of the non-technological issues that will bear on the practical effectiveness of the hardware and software infrastructures that are being created to enable collaborations in e- Science; • characterise succinctly the fundamental sources of the organisational and institutional challenges that need to be addressed in regard to defining terms, rights and responsibilities of the collaborating parties, and to illustrate these by reference to the limited experience gained to date in regard to intellectual property, liability, privacy, and security and competition policy issues affecting scientific research organisations; and • propose approaches for arriving at institutional mechanisms whose establishment would generate workable, specific arrangements facilitating collaboration in e-Science; and, that also might serve to meet similar needs in other spheres such as e- Learning, e-Government, e-Commerce, e-Healthcare. In carrying out these tasks, the report examines developments in enhanced computer-mediated telecommunication networks and digital information technologies, and recent advances in technologies of collaboration. It considers the economic and legal aspects of scientific collaboration, with attention to interactions between formal contracting and 'private ordering' arrangements that rest upon research community norms. It offers definitions of e-Science, virtual laboratories, collaboratories, and develops a taxonomy of collaborative e-Science activities which is implemented to classify British e-Science pilot projects and contrast these with US collaboratory projects funded during the 1990s. The approach to facilitating inter-organizational participation in collaborative projects rests upon the development of a modular structure of contractual clauses that permit flexibility and experience-based learning.

Poverty, institutions and interventions: a framework for an institutional analysis of poverty and local anti-poverty interventions

At a time when technological innovations are making our world increasingly smaller and our production systems are becoming increasingly more efficient, the benefits of economic growth and development as a whole have not been able to reach all of society. Indeed, many poor countries, characterised by their disadvantageous position in the global society and continuously plagued by weak governments, internal strife and natural disasters have missed out on many of the benefits of growth and development. Within countries that do gain advantage from the various developments of globalisation, significant groups continue to be excluded from the benefits of this new-found prosperity. It is quite significant that a generalised conclusion such as this is still a reality at the turn of the century, despite decades of national and international effort to promote development and combat poverty.

University accounting and business curricula on sustainability: Perceptions of undergraduate students

The challenge to embed sustainability in the formal curriculum has been troublesome for accounting academics. This study investigates sustainability in the accounting curriculum at a regional university in New Zealand. Sustainability practices are becoming an important issue given that many business activity problems have arisen over the years, unsustainable practices have resulted in societal and environmental damages. There has been an increasing recognition of the need for sustainability teaching in tertiary education. Education plays an important role in equipping graduates with the relevant sustainability skills to make informed decisions towards a more sustainable world. There is a need to examine how students respond to the teaching of sustainability in their courses. This will allow education providers to find out how student perceive sustainability education, and make changes to improve the teaching of sustainability. Literatures have claimed that students have positive attitudes towards sustainability; however, this does not mean that students are familiar with the concept of sustainability. There are business students who seem to perceive the study of sustainability to be less important when compared to other subjects. There still seems to be a shortage of research done on how students perceive sustainability. This paper contributes to the discussion needed to understand what sustainability skills are required by managers and how tertiary education programs in accounting may need to incorporate sustainability. The role of accounting schools in leading and managing change towards sustainability must be further informed