Quasi Market Research Articles

Is GP Restratification Beginning in England?

English National Health Service general practice is being restructured through the introduction of primary care groups (PCGs) and trusts (PCTs), and the personal medical services (PMS) schemes. Theories of GPs’ professional organization have to be modernized accordingly. Past theories have tended to concentrate on the occupational level rather than consider the effects of different forms of market and quasi–market on practitioners’ income and their ability to control their everyday practice. This paper extends the theory of professionalization, as an occupational group’s strategy for control over its work, to cover these matters, and thereby hypothesizes an explanation of GP responses to current changes in NHS primary health care. Case study data from four PCGs and four PMS pilots suggest that general practitioners are responding in some cases by defending enclaves of traditional general practice; in others by concentrating on clinical rather than managerial interests; and in others again by forming a new dominant coalition with NHS managers. Restratification seems to be beginning in NHS general practice although other policy developments may yet prevent it. Researchers should monitor this potentially important change as PCTs form.

The Effect of the Quasi–market on the Efficiency–equity Trade–off in the Secondary School Sector

Britain’s education system was radically transformed during the 1990s following the Education Reform Act (1988). The primary objective of these reforms was to raise educational standards through the creation of a quasi–market based upon greater parental choice and the transfer of control over resources from local education authorities to schools. The purpose of this paper is to investigate the effects of the quasi–market on efficiency and equity in the secondary education sector in England during the 1990s. Two primary questions are addressed. Has the quasi–market led to an improvement in efficiency in the secondary education sector? Has the quasi–market had any adverse consequences on the social segregation of pupils between schools? Using data obtained from the Schools’ Census and the School Performance Tables, we find strong evidence that the quasi–market has led to a substantial improvement in efficiency (as measured by a school’s exam performance and by the productivity of staff) during the 1990s. The same market forces have led to a greater social segregation of pupils between schools.

Performance-based contracting in Wisconsin public health: transforming state-local relations.

In 2000, the Wisconsin Division of Public Health reorganized its allocation of federal and state funds by basing contracts on performance rather than audited costs. This created a quasi market in which the state acted as the buyer and the local health departments as the sellers of public health services. In its first year of operation, the program more effectively defined public health objectives to its funders and constituencies, linked its fiscal accountability more closely to attainment, and documented performance more carefully. In the next two years, the program will focus on improving the quality of objectives and training all parties in negotiation skills. The 2003-6 contract cycle will concentrate on multiyear and multiprogram objectives and a Web-based contract management system. This new contract system will not, however, be established permanently until its long-range impact on funding levels and population health status is known.

Les politiques de santé en Europe : une vue d’ensemble

Inspired by the ideas of Beveridge or Bismarck, health policies in Europe are quite diverse even though common ideas on ‘solidarity’ and the ‘right to health’ in a welfare state underlie them. Although not all these countries experienced the same need for regulations in the early 1980s, they have all developed regulatory policies for controlling the health sector’s growth. With variable methods depending on its public health system, each of these lands is trying to cope with the inflationary tendencies of the usual way of doing business. They are acting on the supply of health care by introducing market or quasi market mechanisms. They are trying to allocate funds so as to balance efficiency and fairness in public health expenditures. And they must take into account the growing concern for health in a new epidemic context. All reforms emphasize decentralization, seek to involve health-care users, assign the state new roles and, thus, modify the rules of the game in this sector. This trend toward reform should not, however, lead us to imagine that the convergence of health policies at the European level will be simple, since each reform represents a specific solution that has arisen out of the particular member-state’s history.

A service in crisis? Reflections on the shortage of nurses in the British National Health Service

A service in crisis? Reflections on the shortage of nurses in the British National Health Service

Primary care purchasing. Are integrated primary care provider/purchasers the way forward?

Integrated primary care provider/purchaser organisations are currently being developed in the UK and other countries. In common with many other European countries and New Zealand, there has been a swing away from market-orientated models of healthcare organisation towards models which blend centralised planning and quasi market approaches. Primary care groups in the UK and independent practice organisations in New Zealand provide new opportunities to combine micromanagement techniques in the delivery of patient care and approaches to improving population health. These new organisations are building on the experience of health maintenance organisations (HMOs) in the US and physician-led purchasing in the UK and other countries. However, there are distinct differences between countries due to differences in health and social care systems and the degree of emphasis on primary physician involvement. Moreover, the continuing emphasis on a physician-led medical model may be at odds with developing a public health approach which emphasises participative and collaboration with local populations and other primary care providers--an area where physicians have little experience.

Market as metaphor in central and East European higher education

Markets constitute the very centre of the post-communist reforms in the countries of Central and East Europe and the former Soviet Union. The two alternative approaches available for framing the market reform conceptually are, however, both inadequate. Those in favour of revolutionary theories fail to see the strong inertia of the academe and its desire for stability. Proponents of evolutionary theories of market reforms do not recognise qualitatively new relationships in many areas. Those eager to demonstrate the success of the market reforms as well as those presenting the success of the centralised higher education in a number of areas fail to realise the lack of legal framework for market reforms and missing political decisions on which the reforms could be based on. This article discusses the role of labour markets, markets of degrees and qualifications as well as the market of educational services as related to higher education reforms. It is proposed that downsizing the State has shifted many of its previous functions to random, often external agents. This creates a meta-level market - the market of market reforms in higher education. Through this quasi market formerly unified higher education systems and even institutions are broken into segments often ignoring each other's existence and seeking individual short term goals. As a result markets' pressure on higher education has taken extremely aggressive forms limiting access to quality higher education while the systemwide enrolment is rapidly growing through theactivities of new low calibre universities and diploma mills.

Large-scale organizational and managerial change in health care: a review of the literature.

This paper takes an overview of the organizational and managerial literature on recent large-scale change efforts within health care organizations. Such literature refers to issues of enhanced policy significance, as a succession of such changes has swept through health care, at an international level. Interpretive and case study method have been widely employed in this field. While the literature is emergent, key empirical concerns can be identified: (1) Changing roles and relationships, with the rise of management and the challenge to clinical domination; some argue that radical deprofessionalization now is evident, while others take a more nuanced view. (2) The impact of marketization, with health care becoming more of a commodity; various models of a health care 'quasi market' have been formulated. (3) Understanding the process of change in health care organizations, such as the development of a management of change literature. New theoretical frameworks have been developed, notably 'the reform cycle' as a way of understanding progressive cycles of organizational reform, the impact on health care of the rise of the new public management, and examining the demedicalization thesis through the more generic literature on professions. The paper concludes with a discussion of what this research base could contribute to policy-making.

The Quasi Market in Health Care: Pre-requisites, Problems and Prospects

This paper evaluates the operation of the quasi market in health care after the implementation of the reforms set out in the White Paper ‘Working for Patients’ (DoH, 1989a), which replaced the largely state run monopoly provision of health and social services by a state financed internal market. Lying behind the reforms was the assumption that the move away from bureaucratic, to market oriented, systems in the allocation of health and social care would lead to improvements in service efficiency, and responsiveness. This was to be achieved by separating state authorities' purchasing and providing roles, and the introduction of contracts. Using the framework developed by Le Grand and Bartlett (1993), this paper assesses the extent to which the internal market for acute services in Northern Ireland is meeting the expected outcome criteria of efficiency, responsiveness, choice, quality and equity. A survey of purchasers and providers of acute hospital services was conducted, followed by in-depth interviews with the stakeholders in the contracting process. Analysis of the quantitative data, and preliminary consideration of the qualitative data, would indicate that the potential benefits are yet to be fully realised.

Marketization, Managers and Moral Strain: Chairmen, Directors and Public Service Ethos in the National Health Service

Survival of the public service ethos in Britain has been called into question following introduction of the ‘new public management’ and marketizing reforms in much of the public sector. This article examines how these developments have occurred in the NHS, using survey data to analyse NHS board members’ substantive ethical values. Unexpectedly the results suggest that NHS board members with a predominantly NHS background appear less ethically conservative, more flexible and less risk–averse than those recruited from non–NHS backgrounds; and that as yet the NHS management ‘culture’ is not very homogenous in respect of ‘business ethics’. The NHS reforms also appear to accentuate the tensions between transparent public accountability in NHS management and incentives not to publicize certain types of information. Recent codification of NHS ‘business ethics’ can be understood as an attempt to buttress the public service ethos against the increased moral strains of a quasi–market.

Developing a market orientation in the Health Service: a survey of acute NHS Trusts in Scotland.

Argues that the introduction of the quasi market mechanism into the Health Service has required that managers within NHS trusts acquire new managerial skills relating to market operations and, more importantly, reorientate their organizations towards the marketplace. Examines the pattern of development which has occurred within acute trusts across Scotland in the past three years, and argues that managers in the majority of trusts have developed a remarkably robust and relevant conceptualization of the nature and application of marketing within the NHS, reflecting the difficulties managers have faced in selling the concept of marketing to a generally sceptical body of clinicians. Notes, in part owing to such professional scepticism, that the development of marketing as an implementable approach to operations has lagged significantly behind the managerial conceptualization, although this cannot be attributed solely to resistance from clinicians and other health care professionals. Rather, suggests that such limited progress in implementing a market orientation reflects a range of "structural" barriers, both within individual trusts and the specific market environment faced by trusts.

Community Health Services and Managerialism

In this paper, the impact is described of the introduction of the new public management (NPM) on community health services in Australia. From the late 1980s NPM techniques, modelled largely on private sector practices, have been popular with federal and state governments and have affected the management of community health services. Services have been amalgamated, asked to evaluate their work in inappropriate ways and been pressured to a quasi market form of operation. Three fundamantal differences between a primary health care and NPM approach to management are defined and discussed: whether the focus is on individuals or societies, whether it is on public service or profit, and whether it is on meaningful outcomes or those which appear measurable. The paper concludes with a call for the evaluation of the NPM and a return to a more civic and socially focussed public management.

The Americanization of the British National Health Service

The core reform of the British National Health Service (NHS) was the establishment of a quasi market with a split between purchasers and providers. Health authorities and general practitioner (GP) fundholders were to be discriminating purchasers seeking more efficient and responsive services. This market orientation was embedded in a larger context of managerial, allocational, public health, and primary care changes. This paper reviews the background and dynamics of these modifications and offers an early assessment. There is evidence that the reforms have unleashed much energy, activity, and thoughtfulness about future health care, but it remains unclear whether the gains justify the increased administrative and other transaction costs and potential threats to equal access.

The UK health reforms: The fundholding experiment

In April 1991 the UK embarked on the most radical reforms of its health care system in 50 years. Unusually it employed two quite distinct models of quasi market reform. One made District Health Authorities the purchasers of hospital and community health services. The other gave family doctors the money to buy these services on behalf of their patients. This latter model was the most radical part of the NHS reforms. This paper reports on a project that has monitored the family doctor fundholding scheme in detail.

Restructuring Educational Governance: A Challenge of the 1990s

The author argues that there is a critical need for research and scholarship into the impact of educational governance structures (the formal arrangements for making and administering public policy on education) on the native and quality of decisions made and the degree of success in implementing those decisions. The author notes the new directional shift of the current educational reform movement from a centralized bureaucratic emphasis to a more decentralized quasi market orientation and links them to similar societal trends associated with the information age revolution. A framework for conceptualizing the problem of allocating decision-making authority about education among interested parties is presented an (discussed using illustrations from the United States, England, and Australia. Research issues are identified.

Intermunicipal Competition, Budget-Maximizing Bureaucrats, and the Level of Suburban Competition

Government in the United States is often perceived as being too large. Theoretically, competition in the political marketplace is a corrective to such overly large government. For example, competition between municipal governments in metropolitan regions long has been identified as a potential means to limit the size of local government by simulating a quasi market for public goods and services. In this article I identify several sources of intermunicipal competition in polycentric metropolitan regions. I test empirically the effects of such competition on the size of suburban municipal budgets. I find that competition, as reflected in a greater number of alternate providers and by a wider range of choice in the tax price of local government, does in fact act as a restraint on the size of government by increasing the ability and incentives for residents and politicians to control the budget-maximizing tendencies of local bureaucrats.

An Analysis of the 1964 Wheat Option

AbstractWheat farmers operate in a quasi free market in which guaranteed price minima are available upon satisfaction of governmental imposed preconditions. A method is developed with which farmers can evaluate the profitability of available alternatives. In general, there must be sufficient land so that the acreage of wheat relative to the allotment exceeds the ratio of the loan rate to the expected free market price. These break even criteria can be used by policy planners to evaluate proposed programs and to determine their efficacy before their implementation. Ideally, programs should be structured so that the most profitable alternative for the farmer is also the one that will achieve the policy goal. An analysis of statewide aggregate data confirms the theoretical conclusion, based on this methodology, that full participation without additional voluntary diversion was the most profitable alternative open to the wheat farmer in 1964.