THE CHANGING NATURE OF RATIONING IN THE UK NATIONAL HEALTH SERVICE

Article Abstract:

This paper presents findings from empirical research exploring recent developments in healthcare rationing in the UK, and how far these were influenced by the National Health Service (NHS) internal market. Results suggest explicit rationing has continued to spread, but the focus has shifted from exclusions of whole treatments from NHS provision towards a reconciliation of implicit and explicit approaches. There is growing interest in explicit criteria to guide decision making, within which clinicians exercise discretion in individual cases. The market contributed to the growth in explicit rationing, notably by decoupling healthcare purchasers (health authorities and GP fundholders) and providers (hospital and community health services) from their previously shared responsibility to manage resources. However, other factors have been influential, especially concern to control rising expenditure. Having originally prompted more explicit decisions (especially exclusions), resource pressures are now rekindling interest in fixed provider budgets and implicit clinical decision making. The paper concludes by considering the implications for rationing of proposals to abolish the NHS internal market.

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EXPLORING CONTRACTS AS REINVENTED INSTITUTIONS IN THE DANISH PUBLIC SECTOR

Article Abstract:

Contracts have been on the agenda in public sector reform in most OECD countries. In Denmark, contracts have been considered as one of the most important tools in reorganizing the public sector. The article examines the implementation of contract agencies in central government in Denmark during the 1990s. First, a review of contractual theory distinguishes between `hard' and `soft' contracting. Second, recent developments in contracting in Denmark are examined, and three phases of contract agencies are identified. Contracts have been supported by other tools for reporting on performance like annual reports. Third, it is argued that Denmark has put co-operation and negotiation before more strict management and control. The Danish experience can be seen as an alternative to the principal-agent model. The article finishes by discussing the pros and cons of the Danish approach, and suggests that although the pragmatic approach has merits, it may lead to problems in the future concerning the credibility of the whole project.

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