Institutional logics and responsive government: Hospital sector reforms in England, Japan and Sweden, 1990-2006.

This thesis examines the mechanisms of policy change in the hospital sector in three countries (England, Sweden and Japan), and argues that pressure on central government to respond to public concerns can significantly alter conventional institutional arrangements. By analysing four types of pressure (two mainly political, i.e. local campaigns against hospital closure and corporatisation of public hospitals; two mainly technical, i.e. quality assurance system-building, and malpractice incidents), the thesis sheds light on the fact that, when institutional vulnerabilities are exposed to public criticism, central governments exhibit their capacity to reform the hospital sector irrespective of institutional constraints. Under these circumstances, the varieties of the institutions in the three countries do not matter, as the observed responses were similar. In order to compare and contrast the 'responsiveness' of central government within the different 'logics' of the respective health care systems, this thesis investigates selected parliamentary and unitary states with universal health coverage, each however with different degrees of state involvement in the hospital sector: England (nationally-run) as part of the United Kingdom, Sweden (locally-run) and Japan (predominantly privately-run). By differentiating the types of pressure and examining the saliency of each issue in the printed media, it is demonstrated that the responsiveness of government to pressure is largely affected by the institutional arrangements in which they operate. However, when the saliency of non-redistributive technical issues is high, institutional constraints are overcome and institutional choices by government are reversed under heightened pressure. The analysis of dynamic policy change questions the constraining nature of political institutions on health reforms, and explains how policy convergence comes about to an extent that goes beyond path dependency in this predominantly profession-driven policy sector

Regulating risks in healthcare in Japan: Between new politics and the tradition of liberal practice in medicine

Liberal practice in the medical professions has long been the tradition and de-facto position of the Japanese government. However, accountability and transparency in healthcare governance have recently drawn scrutiny, primarily due to several adverse events in hospitals. While New Public Management and risk-based approaches have not penetrated the design of regulatory management and compliance strategies, there has been increased institutional capacity and a search for a new mechanism of regulating risks in healthcare. This paper attempts to identify the directions of policy developments in Japan. It questions whether the conventional model of professional self-regulation in medicine is eroding, as in many English-speaking countries. The article demonstrates that while we may identify some common trends such as greater transparency and the creation of arm’s length bodies, policy decisions prove deeply embedded in governance arrangements, and professional self-regulation in healthcare remains resilient, particularly in Japan.University College DublinPfizer Health Research Foundatio

Scottish Devolution: A Slippery Path towards Consensus Democracy?

Anglo-Japanese Academy Workshop for Young Social Scientists, 4-6 and 9 September 2001, International Center for Comparative Law and Politics, Graduate School of Law and Politics, University of TokyoThe aim of this paper is to show how constitutional change has come to realisation in Britain by focusing on Scottish devolution and also to point out that, in spite of many changes occurring in the British party system and structures, as well as regional government framework, the British political system will not alter until consensus on majoritarian decision-making is further eroded. This paper is divided into three parts: the first part will discuss the merits and demerits of consensus democracy. The second part will examine the progress of Scottish devolution historically and critically review conventional hypotheses about devolution. The last part will highlight one of these hypotheses that focuses on social cleavage and party system change in Britain in order to elucidate the constitutional constraint the British political system has on a much stronger impact on reforms. In this paper, Scottish devolution is focused on because it sheds light on a process of how the majoritarian system operates and has led to a constitutional change, primarily by the active roles played by the two major parties. Scottish devolution and yet unaccomplished electoral reforms for parliament in Westminster are in sharp contrast. Both arguments for fairer representation and more direct democracy started to come to political fore in the 1960s and only the latter has been seriously taken up by the Labour party, since post-war consensus1 between Conservative and Labour party about constitutional frameworks and economic management was broken down in the late 1970s and only when the party got back to power in 1997, devolution scheme was eventually implemented. It has taken almost twenty years to fulfill this goal. However, this still does not automatically result in consolidating the way towards consensus democracy. In conclusion, Britain still constitutes the majoritarian model even today, although there is some scope for change.AM

Bringing the family in through the back door: the stealthy expansion of family care in Asian and European long-term care policy

In the era of global ageing, amid political concerns about increasing care needs and long-term sustainability of current care regimes, most high-income economies are seeking to minimise the use of institutional care and to expand formal home care for their older populations. In long-term care reforms, concerns about public funding, formal providers and the paid care workforce are foremost. However, an integral yet hidden part of all these reforms is the stealthily growing role of family carers. This article aims to identify and spell out how developments in formal home care bring about different modes of increasing, encouraging and necessitating family care inputs, across welfare states. Using secondary sources, three different modes were identified, and the article outlines the logic of each mechanism, drawing on illustrative examples of policy dynamics in both European and Asian countries. Family care inputs have increased through policy changes that are not explicitly or primarily about family care, but rather about expansion or changes in formal care. In some cases, this is explicit, in other cases something that happens 'through the back door'. Nonetheless, in all cases there are implications for the family caregivers' time, health and employment options. Future studies are needed to examine longitudinal trends from a comparative perspective to confirm our findings and elucidate how government commitments to formal home care provision and financing interact with the changing nature and volume of family caregiving

Professional practice following regulatory change: An evaluation using principles of “Better Regulation”

Background: The provisions in place internationally to regulate the practice of healthcare professionals have undergone significant change. However, this changing regulatory environment as experienced by healthcare professionals in the practice setting has not to date been widely researched. Objective: To describe the “lived experience” of pharmacists in community practice in Ireland of the model of regulation introduced by the Pharmacy Act 2007 and their perception of it as fulfilling the seven principles of “better regulation”: Necessity; Effectiveness/Targeted; Proportionality; Transparency; Accountability; Consistency and Agility. Method: 20 community pharmacists purposively selected, shared their lived experiences of the Act, as implemented in a semi-structured interview. A qualitative content analysis incorporating a framework analysis based on the seven principles of better regulation was used to analyze the data. Results: The Act and its implementation by the Pharmaceutical Society of Ireland (PSI) was not perceived by community pharmacists overall as fulfilling the principles of better regulation. While there was agreement that the Act was necessary, its implementation by the PSI was not viewed as being effective, targeted, proportional and consistent. The PSI was considered to act as a deterrence regulator that is not adequately transparent or accountable. The Act is not sufficiently agile to respond to changes in pharmacy practice. Conclusion: Community pharmacists acknowledge the need for the Pharmacy Act but perceive that the PSI needs to adopt a more responsive approach to implementation if the Act is to be considered a model of better regulation. The study findings are of interest as there is little published research on how regulation is experienced by healthcare professionals who are subject to its provisions. The principles of better regulation provide an effective qualitative methodology to examine models of professional regulation based on the “lived experience” of regulatees

Accountability, organisational learning and risks to patient safety in England: conflict or compromise?

This article examines the current risk regulation regime, within the English National Health Service (NHS), by investigating the two, sometimes conflicting, approaches to risk embodied within the field of policies towards patient safety. The first approach focuses on promoting accountability and is built on legal principles surrounding negligence and competence. The second approach focuses on promoting learning from previous mistakes and near-misses, and is built on the development of a ‘safety culture’. Previous work has drawn attention to problems associated with risk-based regulation when faced with the dual imperatives of accountability and organisational learning. The article develops this by considering whether the NHS patient safety regime demonstrates the coexistence of two different risk regulation regimes, or merely one regime with contradictory elements. It uses the heuristic device of ‘institutional logics’ to examine the coexistence of and interrelationship between ‘organisational learning’ and ‘accountability’ logics driving risk regulation in health care

Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness

Learning from patient safety incidents is difficult; information is often incomplete, and it is not clear which incidents are preventable or which intervention strategies are optimal. Effective group processes are vital for learning but few studies in healthcare have examined in depth the processes involved and whether they are effective. The aims of this study were to identify factors that facilitated and hindered the process of analysing incidents in teams and to develop and apply a framework of indicators of effective analytic processes. Incident review meetings in acute care and mental health care were observed. Full field notes were analysed thematically. A framework of process measures was developed and used to rate each meeting using the field notes. Reliability was analysed. Factors hindering analysis were lack of organisational support, high workload and a managerial, autocratic leadership style. Facilitating factors were participatory interactions and strong safety leadership. Process measures showed deficits in critiquing the causes of incidents, seeking further information, critiquing potential solutions and solving problems that crossed organisational boundaries, supporting observational data on the importance of effective leadership. Organisational legitimacy, administrative support, training, tools for incident analysis, effective well trained leaders who empower the team and sufficient resources to manage the high workload were all identified in this study as necessary changes to improve learning. Future studies could develop and validate the proposed framework of process indicators to provide a tool for teams to use as an aid to improve the analysis of incidents.National Institute for Health Research (NIHR

How prepared are nurses and midwives for quality improvement and patient safety?A cross-sectional national study in Ireland

Background: Although patient safety and quality are cornerstones of healthcare practice, evidence is limited of the knowledge, skills and competence of practicing nurses and midwives in Ireland. Objectives: To investigate the perceptions of nurses and midwives regarding their continuing professional development-based preparedness for, and participation in quality and safety in the clinical setting. Design: A cross-sectional survey was undertaken across the Republic of Ireland in 2016 examining nurses and midwives' perceptions of their knowledge and skills in quality and safety methods and tools, their views of competence in this field using the domains from the Quality and Safety Education for Nurses (QSEN) framework (person-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics), and their participation in practice related to their access to quality and safety data. Settings: 12 Health Service Executive (HSE) Centers of Nursing and Midwifery Education (CNMEs) in Ireland Participants: Practicing nurses and midwives (n = 654) working in acute hospitals and community healthcare organizations who were undertaking continuing professional development (CPD) education at the time of data collection (March–April 2016). Methods: Survey methodology. 1787 surveys were distributed. Data were analyzed by IBM Statistical Package for the Social Sciences. Results: A response rate of 37% (n = 654/1787) was achieved. While respondents were highly trained academically, many reported a lack of confidence in quality and safety methods and tools and QSEN competencies. Frontline staff nurses and midwives reported they were less prepared than their mid and senior level colleagues. Significant numbers indicated they were not engaged in quality and safety in practice. Conclusions: This first nationwide study in Ireland has discovered that nurses and midwives perceive gaps in their preparedness to engage in quality improvement and patient safety in practice. To safeguard patient care, priority should be given to ensuring front-line staff are appropriately educated, have access to data, and time to competently participate in the continuous improvement of patient care

Questioning World Risk Society: Three Challenges for Research on the Governance of Uncertainty

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