INTERROGATING INSTITUTIONAL CHANGE: ACTORS' ATTITUDES TO COMPETITION AND COOPERATION IN COMMISSIONING HEALTH SERVICES IN ENGLAND
| Author | NEIL PERKINS,MARIE SANDERSON,DOROTA OSIPOVIČ,KATHERINE CHECKLAND,LORRAINE WILLIAMS,ELIZABETH SHEPHERD,PAULINE ALLEN,ANNA COLEMAN |
| Date | 01 September 2016 |
| Published date | 01 September 2016 |
| DOI | http://doi.org/10.1111/padm.12268 |
doi: 10.1111/padm.12268
INTERROGATING INSTITUTIONAL CHANGE: ACTORS’
ATTITUDES TO COMPETITION AND COOPERATION IN
COMMISSIONING HEALTH SERVICES IN ENGLAND
DOROTA OSIPOVI ˇ
C, PAULINE ALLEN, ELIZABETH SHEPHERD,
ANNA COLEMAN, NEIL PERKINS, LORRAINE WILLIAMS, MARIE SANDERSON
AND KATHERINE CHECKLAND
Since the beginning of the 1990s the public healthcare system in England has been subject to reforms.
This has resulted in a structurally hybrid system of public service with elements of the market.
Utilizing a theory of new institutionalism, this article explores National Health Service (NHS) man-
agers’ views on competition and cooperation as mechanisms for commissioning health services. We
interrogate the extent of institutional change in the NHS by examining managers’ understanding
of the formal rules, normative positions and frameworks for action under the regime of the Health
and Social Care Act 2012. Interviews with managers showed an overall preference for cooperative
approaches, but also evidence of marketization in the normative outlook and actions. This suggests
that hybridity in the NHS has already spread from structure and rules to other institutional pillars.
The study showed that managers were adept at navigating the complex policy environment despite
its inherent contradictions.
INTRODUCTION
Studying the process of institutional change is one of the core preoccupations of scholars
of public administration. Such processes are often elusive and their consequences are hard
to predict. This article explores the process of institutional change by analysing different
actors’ views of the regulatory structures which guide commissioning of healthcare in the
quasi-market of the English National Health Service (NHS) under the regime of the Health
and Social Care Act 2012 (HSCA 2012).
The efforts to instigate institutional change towards greater marketization of the English
NHS date back to the beginning of the 1990s when the hitherto unied local health author-
ities were split into state-owned purchasing organizations (or commissioners) acting on
behalf of patients and state-owned providers of healthcare for local populations (DH 1989;
Paton 2014). Since then successive UK governments have enhanced elements of compe-
tition by introducing policies designed to increase diversity of organizational types of
providers, allowing patient choice and commercializing the terms of procurement and
contracting within the English NHS (DH 2005). Most recent reforms to the English NHS
contained in the HSCA 2012 reinforced this direction of change by introducing formal leg-
islation encouraging competition between providers. Overall, the process of institutional
change has resulted in hybridization of the NHS and utilization of the market alongside
the pre-existing political hierarchy as modes of social control (Allen et al. 2011).
Healthcare is not the only public service sector that has experienced a shift towards mar-
ketization in the UK since the 1980s. There has been a somewhat unreective extension of
the notion of consumer choice taken from the private sector to social housing and edu-
cation, despite big differences in the type of constraints characterizing the quasi-markets
Dorota Osipoviˇ
c, Pauline Allen, Elizabeth Shepherd, Lorraine Williams and Marie Sanderson are at the Department
of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK. Anna Coleman, Neil
Perkins and Katherine Checkland are at the Centre for Primary Care, University of Manchester,UK.
Public Administration Vol.94, No. 3, 2016 (823–838)
© 2016 John Wiley & Sons Ltd.
824 DOROTA OSIPOVI ˇ
CET AL.
in each eld (Greener and Powell 2009). On the supply side, the provision of many pub-
lic services has been supplemented by or outsourced outright to private and third sector
organizations, for example in education (Goodman and Burton 2012) or ‘welfare to work’
support (Rees et al. 2014).
As a result of 25 years of market reforms, the NHS in England constitutes a structural
hybrid featuring quasi-market structures, private and third sector providers, market regu-
lators and some (albeit limited) consumer/patient choice (see e.g. Allen et al. 2011). How-
ever, the extent to which the encroaching marketization has permeated mind sets and
practices of NHS managers and clinical staff is debatable (Mannion et al. 2009; Checkland
et al. 2012). This article provides new empirical insights on this matter.
The study reported here examined how managers in commissioning and providing
organizations related to and dealt with the marketization of NHS structures. The pur-
pose of this article is to report and analyse NHS managers’ attitudes to competition and
cooperation in the NHS under the regime of the HSCA 2012. By analysing managers’
understanding of the rules, normative views and actions in respect of the mechanisms
of competition and cooperation in the NHS, we interrogate the process of institutional
change itself, together with the extent to which marketization has become an internalized
feature of commissioning practices. We nd signs of marketization in the norms and cog-
nitive frameworks employed by some NHS managers. However, rather than a wholesale
market turn, they reect creative incorporation of some market principles into everyday
commissioning practices mostly favouring collaborative working.
Weview the HSCA 2012 as one event among many along the continuum of institutional
change put in motion by the introduction of a quasi-market at the beginning of the 1990s.
While adhering analytically to the longue durée perspective, in this article we assess the
role of the HSCA 2012 in the process of marketization of the NHS as the most recent and
controversial event (see e.g. Reynolds et al. 2012).
We used a case study design, selecting four local health economies in England. In
each site we investigated the views on competition and cooperation of senior managers
in both providing and commissioning organizations. Arguably, focusing on managers
as ‘street-level bureaucrats’ is key to detecting any ‘real’ institutional shifts in the NHS
(Pettigrew et al. 1988). This is because they hold the power of either translating structural
changes into practices or hampering such processes. We looked for signs of hybridity in
their normative outlook and agentic dispositions, and explored how individual actors
within organizations in different local contexts dealt with the structural hybridity of
the NHS. By focusing attention on the level of individuals within the organizations, the
study contributes to the literature on diversity of normative and agentic responses to
structural hybridity (e.g. Denis et al. 2015; Skelcher and Smith 2015; Waring 2015). The
article also addresses the currently under-researched empirical question concerning the
extent to which hybridity occurs at different levels of analysis and in different institutional
dimensions (Denis et al. 2015).
NEW INSTITUTIONALIST PERSPECTIVE ON HYBRIDIZATION OF THE NHS
We chose Scott’s (2008) approach to new institutionalism to ground our analysis. Scott
(2008, p. 48) views institutions as relatively resistant to change and ‘comprised of regu-
lative, normative and cultural-cognitive elements that, together with associated activities
and resources, provide stability and meaning to social life’. According to Scott, the three
institutional pillars both enable and constrain actors’ behaviour in distinctive ways. The
Public Administration Vol.94, No. 3, 2016 (823–838)
© 2016 John Wiley& Sons Ltd.
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