Discretion drift in primary care commissioning in England: Towards a conceptualization of hybrid accountability obligations

Abstract

In the context of welfare delivery, hybrid organisations mix public and ‗new' market, social, and professional types of mechanisms and rationales. This paper contributes to our understanding of accountability within hybrid organisations by highlighting how accountability obligations can become hybrid, simultaneously formal and informal. Instead of seeing accountability as hybrid only in the sense of the coexistence of types of organisational mechanisms and structures (i.e., the prevalence of both state and market types), we examine accountability arrangements governing a hybrid modelprimary care commissioning in Englandand interrogate the relationships between accountability actors and their accountability forums. We conceptualise ‗hybrid accountability obligations' as a state whereby the nature of obligation underpinning accountability relationships is

On the character of the new entrepreneurial National Health Service in England: Reforming health care from within?

“…2019; Gore et al . 2020). This generates an empirical question about the strategies adopted by staff to reconcile the conflicting tensions resulting from the interconnection of divergent logics (Bailey et al .…”

“…Successive political initiatives over decades (see Table 1) have produced a complex and conflicted policy landscape with discourses and practices associated with both competition and collaboration, centralization, and devolution and other forms of hybrid governance (See Figure 1). In practice, the shifts depicted in Figure 1 have resulted in ambiguity in governance at strategic and operational levels, which has produced increasing heterogeneity at the practice level as different organizational and spatial boundaries shift (Gore et al 2018;Gore et al 2020).…”

“…Together these changes have produced a complex, “hybrid” system in the NHS (Gore et al . 2020; Thynne & Wettenhall 2004) in which quasi‐corporate organizations interact within a quasi‐market comprising both public and private bodies (Exworthy et al . 1999), with several semi‐autonomous and arms‐length bodies outside central government providing strategic direction and oversight (Hammond et al .…”

“…This shift has also been accompanied by a retreat by the state in some areas of health service provision, such that there has been an increase in out-of-pocket expenditure; in the United Kingdom, this represents 16.7% of all health expenditure (https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS). Together these changes have produced a complex, "hybrid" system in the NHS (Gore et al 2020;Thynne & Wettenhall 2004) in which quasi-corporate organizations interact within a quasi-market comprising both public and private bodies (Exworthy et al 1999), with several semi-autonomous and arms-length bodies outside central government providing strategic direction and oversight (Hammond et al 2019). Within this hybrid system, the evolution of corporatization over the last 20-30 years has necessitated more entrepreneurial behaviors across public services (e.g., Currie et al 2008).…”

French Idiosyncratic Health-Care Reforms, Performance Management and Its Political Repercussions

“… 24 While physician's prerogatives have receded and government reforms contributed to a weakening of physicians’ trade unions, these remain influential at the local level (e.g., in many rural areas, the city mayor is often a retired physician), and could not be ignored. Unlike the split between the commissioning and the provision of health services in the British NHS, 25 , 26 French physicians were hardly willing to play one care provider (e.g., hospitals, laboratory) against another to demand better-contracting terms such as faster services for patients or lower costs for the Social Security. In contrast to the British general practice Consortium 27 and fundholding practices 28 that represent several thousand patients and thus exert some bargaining power when negotiating with care providers, French solo-practice physicians lack sufficient clout to make any difference during fee negotiation with care providers.…”